Leadership Lessons for the NHS. Is Francis Right? - IEDP
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Leadership Lessons for the NHS. Is Francis Right?

Emphasising rules-based clinical risk controls may produce unintended consequences


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Are the right leadership lessons being learnt from the chronic failures at the Mid Staffordshire NHS Hospital – where up to 1,200 patients are thought to have died unnecessarily between January 2005 and March 2009? Recent academic research suggests that the recommendations made last week in the Francis Report, a public inquiry ordered by the UK parliament, may produce unintended consequences by emphasising rules-based clinical risk controls.

As the NHS is state run, an angry British public is demanding state intervention - punishment of those responsible (incredibly the man in overall charge at the time is now head of the entire English NHS) and, supported by Francis, more regulations imposed from above. This understandable knee-jerk reaction ignores the leadership ‘best practice’ present at many well managed private sector corporations and preached by all the best international business schools.

In his report Francis describes a culture of fear, secrecy and defensiveness in which whistle-blowers were silenced and relatives ignored, where hospital managers focused on narrow bureaucratic targets and put corporate self-interest and cost control ahead of the quality of care and patients’ safety.

Drawing on their latest research, Michael Fischer of Saïd Business School Oxford and Ewan Ferlie of King’s College London argue that “rules to enforce openness, transparency and candour among NHS staff can create an impetus for change, but increasing micro-regulation of clinicians and managers is likely to undermine rather than support high-quality patient care.”

“In the Francis recommendations, we are seeing a shift from micro-management to micro-regulation of clinicians and managers” says Fischer. “What is actually needed is a reanimation of the health professions, to reinvigorate professional values and ethics-based self-regulation. Instead, increasing micro-regulation across the NHS is likely to aggravate tensions between externally focused regulation, orientated towards transparency, accountability and external scrutiny, and locally important values of delivering high quality care. Paradoxically, the Francis recommendations extend regulation still further as a dominant idea which is misguided.”

“We argue that micro-regulation is not going to bring about culture change needed. We would like to see efforts to encourage a reinvigoration of the health professions, especially nursing, to allow ethics-based care and self-regulation to become more dominant, underpinned by rules-based standards as a fail-safe when things go wrong”, adds Ferlie.

Fischer and Ferlie’s study, published in January, explores how the imposition of external clinical risk control goals at one NHS unit produced a ‘box-ticking’ culture that protected managers from criticism, while patients and staff lost confidence in each other. “Introducing rules and targets increased tension and encouraged finger-pointing between staff, NHS managers and patients,” explains Fischer, a former clinical consultant.

The research conducted over a period of four years, revealed how a values-based system where staff and patients collaborated to reduce risks to patients disintegrated when the NHS Trust enforced external safety and clinical standards.

Describing events at the Stafford Hospital as "a despicable catalogue of clinical and managerial failures", Prime Minister David Cameron declared: "I love our NHS… Whoever you are, wherever you're from, whatever's wrong, however much you've got in the bank, there's a place you can go where people will look after you," he said. "The shocking truth is this precious principle of British life was broken."

Some would see the scandal of ‘private sector’ healthcare in the US as being its inaccessibility to the poorest citizen. Part of the NHS scandal is the blind-eye turned by ‘public sector’ managers to modern leadership best practice centred on ethical behaviour, trust and human values. Coincidentally or not, in a quick survey, IEDP found very few high-level leadership programs aimed at healthcare managers being run at UK business schools whereas the US boasts many as represented by the Business School Alliance for Healthcare ManagementUniversity

The Saïd Business School is Europe’s fastest growing business school. An integral part of the University of Oxford, it embodies the academic rigour and forward thinking that has made Oxford a world leader in education.

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