The much-anticipated Francis Report on the Mid Staffordshire NHS Foundation Trust Public Inquiry was published last week. At the centre of the inquiry was the elevated level of Hospital Standardised Mortality Ratios (HSMRs). Essentially this means that death-rates in this trust were higher than would be expected for a trust of this size. It is not our intention here to go through the ‘whys’ and the ‘wherefores’ from the report, there has been enough of that in the intervening 10 days since publication. Rather we want to talk about the ways in which those with vested interests are using this inquiry. The events that happened at Mid Staffs are abhorrent, but this will not stop them being used by those in positions of power for political capital, to undermine public trust in health professionals and to underscore their own political projects for the NHS.
Consider this, Robert Francis (the report author) has refused to attribute an actual number of deaths to this elevated HSMR. He even went so far as to state in the initial 2010 inquiry that “it has been concluded that it would be unsafe to infer from the [elevated HMSR] figures that there was any particular number or range of numbers of avoidable or unnecessary deaths at the Trust.” However, this has not stopped the Daily Mail quoting a figure of 1200 deaths in its coverage. The Telegraph goes one step further and talks of Mid Staffs and needless deaths of ‘up to’ 1200 patients being nothing in comparison to five other rogue NHS trusts collectively accountable for ‘up to’ 3000 unexpected deaths.
This particular approach to the ‘evidence’ brings to mind work on the role of trust in the provision of health care. The headlines from the right wing press speak to a moral opprobrium at the cleaving of the sacred bond of trust between patients and professionals. As a consequence, capital is made of professionals revoking any capacity they may have had to warrant our trust (Dan Hodges blogging in The Telegraph gives a prime example of this). But what does this breakdown of trust say about the wider system of provision, what does it say about ongoing (and well documented) projects aimed at undermining public trust in the professions, often as a means of legitimising ‘free market’ reform of public sector provision?
Mid Staffs, is the latest in a long line of cases, the most frequently quoted others being Bristol and Harold Shipman that are cited in relation to issues of professional trust. It is a given, and accepted by all, that these cases are obscene, but this has not stopped them being used politically, to undermine faith in the professions and to bolster the role of government as the trustworthy party in the exchange of political benefits across healthcare provision. Salter (2004) characterises this political exchange as a triangle of mutual exchange between citizens, the state and the professions. Light, (2010) writing in a similar vein, talks about changes in forms of accountability, such that new modes of professionalism emerge, new models that replace notions of embodied trust with new models of enforceable trust. This enforceable model of trust comes from a position that openly distrusts professionals and requires them to meet centrally imposed standards of effectiveness and efficiency in order to prove their trustworthiness. The problem with this approach is that it locates the blame for Mid Staffs or Bristol or other such cases firmly and squarely on the shoulders of professionals. It ignores the wider political context.
Charles Perrow, in his now classic study of high-risk technologies, warned that it would always be a vast oversimplification to automatically blame the operators of a system when things go wrong.
It is indeed the case that people sometimes do really stupid things, but when most of the accidents in a particular type of system are blamed on the operator, that is a symptom that the operators may be confronted with an impossible task, that there is a system design problem (Perrow 1984)
He identified two dimensions that would predict systems likely to experience catastrophe (or ‘Normal Accidents’): interactive complexity and tight coupling. Interactive complexity simply refers to how the components of a system may interact with one another in intricate and unpredictable ways. Most modern organisations and technologies are interactively complex (hospitals and universities certainly are). This only becomes a problem when they are also tightly coupled – this means that what happens in one place rapidly affects and changes what happens in other places. Chemical plants and nuclear power stations are both interactively complex and tightly coupled. When something goes wrong it can rapidly overwhelm the system with operators being powerless to prevent harm – often they do not even understand what is happening. What the incentivised culture of targets, with patients being rapidly processed, has done is to move hospitals from being loosely coupled (but for the most part safe) – to becoming tightly coupled and complex systems prone to tragedies that the operators are powerless to prevent.
It is interesting that this week, Andy Burnham (the last Labour Secretary of State for Health) stated that the Labour government went too far with the target culture. Perhaps this is something that it is easy to say when in opposition, it is certainly not a sentiment shared by Jeremy Hunt, the current Secretary of State for Health. Hunt’s response has actually been to call for a police investigation into the deaths. Rightly or wrongly, this move clearly functions to underline/vilify professional practice. The question this raises for us, is how does this act of individual blaming and vilification effect a level of systems change that will prevent such events from happening again?