News and Comment

Notes on a scandal: Lessons for Leaders of CCGs

Tuesday 19 February 2013


Everyone loves a good scandal. Usually about power and money, and often about sex, a good public scandal has a strong narrative, a cast of dubious characters and innocent victims, and a whiff of conspiracy and cover-up thrown in for good measure.

Loving a scandal is perhaps an unfortunate characterisation. We are intrigued by scandals because they are high drama. Serialised over days and months, we thirst for new information; we seek accountability from our leaders and our cherished institutions. We react, we accuse, we pronounce: never again!

I’ve been struck by how quickly one scandal replaces another in the British media.

Two weeks ago, we were shocked by the findings of the Francis Report on Mid-Staffordshire NHS Trust.  This was a scandal for the whole of the health service, not just the Trust. On its release, the much-anticipated Francis Report generated considerable hand wringing about poor standards of care across the NHS and what to do about it.

Shortly on the heels of the Francis Report, our attention was diverted by the horse meat scandal – in which it was revealed cheaper horse meat had been substituted for beef in prepared foods. Although frozen burgers, cottage pies and lasagnes were quickly taken off supermarket shelves, we soon learned that the scandal had an even wider impact on unsuspecting and innocent consumers, affecting the food of hospital patients and school children.

What both the horse meat and Mid-Staffordshire scandals illustrate is what can happen when system leadership fails. Consider how much these scandals have in common:

  • Prioritising the controlling of costs over maintaining quality
  • Providers neglecting their responsibilities to assure minimum standards
  • A culture of collusion and bullying across the system
  • Regulators missing vital signs and emphasising process over outcomes
  • Public complaints ignored by officials – in effect, a conspiracy of silence
  • What sets these scandals apart is how they’ve brought our public institutions into ill repute. Both highlight the failure of leaders to protect public safety and result in the erosion of confidence in our public institutions.

What dismays me is the similarity of the official responses for how to fix the problems – the emphasis on better monitoring, inspecting and investigating; the assigning of blame without taking personal responsibility; and calls for greater transparency in system governance. These approaches seem wholly inadequate, and likely to perpetuate rather than resolve the problems that produced the scandals in the first place. Whilst a clamour for immediate and decisive action is entirely understandable in the wake of such scandals, the tendency of authorities to respond with a focus on system regulation overlooks the collective efforts and collaboration required of every player in the system.

Because I work regularly with several newly formed Clinical Commissioning Groups, I’ve been thinking deeply about what their leaders might do to prevent another Mid-Staffordshire from occurring today or in the future. For those who ignore the Francis Report do so at their peril.

CCG leaders have an opportunity to create a different paradigm. Rather than responding in the usual way, they need to see the scandal as a leadership, rather than a process, challenge. That means taking an active role in creating a different sort of NHS culture. They will have to act genuinely as champions for local patients, and working side-by-side with their GP members, they will have to build the capacity to listen, hear, see and know about the healthcare provided in their communities.  This requires investing heavily in relationships, rather than becoming overly reliant on assurance processes.  Most important, they will have to demonstrate compassion when dealing with patients’ complaints.

Robert Francis should be applauded for his detailed exposure of the complex system that led to the failures at Mid-Staffordshire NHS Trust. Yet even after the inquiry, calls for NHS leaders to accept personal responsibility for the system failures persist, and as recent disclosures about United Lincolnshire Hospitals NHS Trust suggest, the experience of one scandal quickly replacing another may again be repeated.

With a third of NHS finance directors reporting concerns about declining quality of care, CCG leaders must heed Mr Francis’s lessons or learn to take notes on a different scandal.