The report from the Francis inquiry into events at Mid Staffordshire Foundation NHS Trust published yesterday does not make good reading. Clearly a lot of patients and their relatives were let down.
When these types of events happen it is clearly big news and distressing for those who used and are current users of the services.
The inquiry was clearly extensive. The executive summary alone was 125 pages long.
While we can never turn back the clock one big message that comes up over and over again is leadership and governance.
In NHS organisations the Chief Executive as Accountable Officer is the organisational leader and when things go wrong the buck stops with them and the fellow Board members.
The Board set the tone at the top. They hugely influence the culture, the extent to which staff are engaged, the way performance is monitored and how decisions are made.
It would appear that there were significant issues with engagement of staff at this Trust.
In this case it appears that failings in leadership extended far and beyond Board level.
Doctors and more specifically consultants did not appear to take a stance for patients and use all channels available.
Nurses who are closest to the point of delivery of care did not appear to speak up or use all channels available to highlight what was going on.
Strategic Health Authorities and Department of Health were found to be lacking in their roles.
Regulators did not appear to be fast enough to spot and take action on concerns.
Professional bodies were not visible or if they were lacked effectiveness.
On one level it is easy to say that it is all down to too much emphasis on managing money and not enough on the quality. The reality is that for quite a long time the NHS has had a focus on targets, financial and operational. Recently there has been a big shift to quality.
To just focus on the money and business approach is too simplistic in my view. NHS bodies like everyone else have to live within the level of resources they have available. At the same time what makes it tougher is that the demand just seems to keep rising. People are taking more care of their health and accessing the services more.
Any organisation that I have been part of understood that meeting targets whether financial and operational had to be done safely. Nursing Directors rightly put their foot down, as did Senior Nurses when it was proposed to make reductions in staffing levels on wards.
So what are the key leadership lessons from this inquiry?
You Are Off Track When You Lose Sight Of Your Core Purpose
The core purpose of an NHS organisation is to serve patients. Everything else is an enabler of delivering that core purpose.
If People Are Not Aligned To A Core Purpose You Just Get Disengagement
Team working in the NHS is tough. There are lots of people working in silos. If people are working in their own silos without being aligned to a core purpose then the focus becomes on self interests.
Not Listening Or Hearing Is Not A Good Long Term Strategy
If leaders are not willing to listen to real concerns then eventually there are going to be outcomes that are going to be significant.
Leadership Is Needed At Every Level
While the Board might be accountable they clearly cannot be everywhere all of the time. Leadership is needed from all professional and non professional staff. The reality is that a Board of a handful of people cannot have their finger on everything that is going on.
Measures Of Performance Need To Focus On What Matters
Standards and targets have their place. They do however need to focus on the factors that contribute to a successful NHS organisation.
Measures Of Performance Need To Be Understandable To Everyone
The measures of performance need to be written in plain and simple language that can be understood by everyone.
Measures Of Performance Need To Be Able To Be Able To Be Routinely Tracked As Part And Parcel Of Doing The Job
Yes we need the high level reporting. At the same time we need those measures that can be easily checked quickly by those closest to the delivery of care.
You Have To Get Into The Front Line A Lot
If any senior clinical or non clinical professional was visible in and around a hospital it would become apparent pretty quickly that all was not well. You see and sense when all is not going well.
You Have To Speak Up
It is hard to imagine that many senior people, clinical and non clinical in the NHS were not aware of issues. Being aware of the issues is one thing. Having the courage to speak up is another thing. Yet in reality part of being a leader is to take a stance and speak up when things are not going well.
You Have To Face Up To Reality
We have an ageing population. People are living longer. Hospitals are very often running at capacity levels that are extremely high and over and above the baseline percentage. The demand on services and hospitals is likely to increase.
Faced with this reality, there has to be a willingness to step back and take a long hard look at how services are provided, where they are provided and the way the service is run. Specific initiatives by themselves while helpful do not go far enough.
The tragic events have clearly had a significant impact on many people and families. Sadly the clock cannot be turned back. There is however an opportunity to learn and restore trust and faith in the NHS and the vast majority of people who go out of their way day in and day out to deliver the best possible services with the resources available. This is the time when we need leadership at every level within the NHS.
Duncan Brodie is Managing Director of Goals and Achievements who help healthcare organisations to improve leadership, management and team working. He worked in the NHS for 15 years, is a former Finance Director and experienced first hand the challenges of running a busy hospital.