I am writing this pre-Francis report, but publication is very soon. Rather than try to second guess the report, I want instead to address both my hopes and my fears for what will be – indeed must be – a pivotal moment for our NHS.
Personally, I have two ‘top hopes’. Firstly, I hope it will jolt the system into putting quality and safety at the top of the list of priorities for the NHS – really, genuinely, and truly at the top. Secondly, I hope it will bring about an era of openness and transparency in all our dealings as NHS managers.
Putting quality and safety first needs more than a simple statement, and to do it properly will lead to some decisions that are very difficult in the current system. Some real world examples of this might be allowing access times to increase rather than opening a poorly staffed flex ward, or recognising that many frail elderly patients have a more life threatening condition than many patients with cancer and prioritising accordingly. Or putting resources into reducing medication errors or pressure sore reduction, rather than further reduction of the now much less frequent MRSA infection.
Genuine openness and transparency will have many consequences too. Listening to the voice of patients, public, and staff will lead to a loud call for different priorities than we currently have – perhaps locally important rather than nationally determined? That in turn will require a different allocation of resources than at present, which in a zero-sum game will have consequences for areas that are ‘de-prioritised’.
As for fears, I have two of those as well. I fear that we will try to ride out the difficult times after publication, make a few minor adjustments, convince ourselves that ‘it doesn’t apply here’, and look to continue much as before. I fear too that we will be forced into more regulation, rather than recognising that a deep culture change is in fact needed. More regulation to solve a problem that regulation failed to prevent?
I am optimistic by nature, and I do think Francis will be a catalyst for significant change. But the centrally-driven, short-term, access target focused culture is deeply embedded and will be difficult to uproot. After all, it works. It has led to vastly reduced access times, to significant reduction in healthcare-acquired infection rates, and to good financial control. But I worry about what hasn’t been achieved, because it was never designed to achieve them – a safe and dignified system of care for the elderly, proactive, morbidity-reducing, home-based care of people with chronic conditions, or urgent care systems that cope comfortably with winter pressures.
We achieved what was right for the time, but time has moved on. What I hear, consistently and repeatedly, is that people want safe, effective, respectful and dignified care that is truly patient centred. And they want it locally-provided by NHS organisations that are joined up around their needs.
I want this too. We can achieve it, I know we can, but it needs a change in culture and approach and not more and harsher regulation.