Monday, 30 November 2009

Basildon and Thurrock University NHS Hospitals Foundation Trust is sick

Reminiscent of the up-one-minute and down-the-next ratings applied by the children’s regulator Ofsted to Haringey’s children and young persons services, something similar is happening now with hospitals and their sector’s regulator, the Care Quality Commission (CQC).

On 27 November, reported that CQC ‘… found that poor nursing, filthy wards and lack of leadership at Basildon and Thurrock University NHS Hospitals Foundation Trust contributed to 400 avoidable deaths in a year. … Concerns about death rates … were first raised a year ago, but an internal investigation failed to find anything wrong and senior managers dismissed the concerns. … The new external report found “systematic failings” in the trust’s senior management team … Yet the trust was rated as "good" on quality of service in the CQC's 2008/09 assessment and marked "excellent" for its financial management. It was also given 13 out of 14 for safety and cleanliness ...’

The inspection system calls for an overall rating (e.g. ‘excellent’); but this cannot capture the variability over multiple aspects which may be marked low, while others may be marked high. How can you average these, and how meaningful is such an outcome? Baroness Young, who chairs the CQC, herself admits that ‘the rating covers about 200 indicators and tries to summarise the performance in a very complex hospital in one word, either 'good', 'excellent', 'fair' or 'poor', I don't think that's right’. What I personally find frustrating is that I was pointing out this problem 15 years ago in the book Developing Corporate Competence!

A way round this rating dilemma would be to rely on narrative descriptions of the component elements; it is the detailed story that contains the potential for learning and improvement. A rating is merely a crude headline that induces anxiety and the threat of managers being replaced, or alternatively leads to relaxation. In a previous round of inspections, hospitals were incentivised to achieve an ‘excellent’ rating by offering them ‘foundation trust’ status, becoming semi-independent of government control. Another hospital, Stafford, was one of those whose executive team tried so hard to achieve foundation trust status that it took its eye of its real goal, that of serving its patients and blamed this for its poor performance! Many of the hospitals that passed the first hurdle and became foundation trusts have now been labelled ‘failed’. But the system of labelling has also failed and has even contributed to that failure. Elementary psychology teaches us, for example, that external inspections are responsible for the situation quoted above; i.e. where a subsequent “internal investigation failed to find anything wrong and senior managers dismissed the concerns”.

Ultimately, it becomes impossible for the leaders of a failed regulatory system, one which has become so corrupted and discredited, to provide their own solution. The remedy usually entails a change in the cycle between central and local control, and between extrinsic and intrinsic motivation. The need for such about-turns is an argument for limiting tenure – not just of chairmen, chief executives and regulators’ chief inspectors, but also governments.

A further issue in the hospitals debacle is that leadership is itself being rated as though it is an independent variable. This presupposes that it would be theoretically possible for all the other measures of hospital success to be rated high while leadership is rated low. Or vice versa. But where the organisation has suffered systemic failure there has, by definition, been a systemic failure of leadership. The confusion over the place of leadership in the inspection regime arises where a distinction is not made between the enterprise’s ‘business’ (what it exists for) and its ‘organisation’ (the internal arrangements that enable it to serve its business). Leadership is in the latter category; it is a means to an end. Incidentally, note the CQC’s reference to ‘systematic failings’ instead of ‘systemic failings’. Leaders who don’t understand systems frequently make this error. ‘Systematic’ means methodical, regular or deliberate – you wouldn’t deliberately set out to fail, would you? ‘Systemic’ means it is a feature of the system.