“The system! I am told on all hands, it's the system. I mustn't look to individuals, it's the system... My Lord knows nothing of it. He sits there to administer the system...HE is not responsible. It's the system." Peter Hay applies Dickensian logic to inquire what the Mid-Staffs scandal meant for social care.
This is the outpouring of rage by Gridley in Bleak House, Dickens' portrait of the grinding and all consuming nature of the Victorian legal system. A system that even the most powerful people inside it were unable to affect. It could equally be an expression of some of the frustration that some felt after a reading of the Francis report. Except for a key difference. Unlike the judges Dickens portrayed, we have the chance to change our system: we are neither powerless nor overwhelmed by it.
I haven't watched social care sit this one out as a problem confined to hospitals run by someone else. We share the ambition of creating dignified and safe health and care systems. Francis is clear that his report must be a call to action, and that includes how we find our way to play our part.
The studied examination of large amounts of evidence and testimony by Francis concludes in 290 recommendations that the deaths of around 1200 people require cultural change within the NHS. For many of us, as well informed members of the health and care system, the call for culture change is easily understood.
Our thoughts should start with the relatives whose " completely understandable anger" in the words of the Prime Minister is perhaps closer to Gridley's rage and confusion.
For some of the relatives, no one seems able to change the system simply because it's too big and too remote. An inquiry is not an end in itself and the Government's response to Francis will have to bridge the gulf between the scale of the task and the need to show momentum towards a better and safer system. It will also need to sit alongside and support the mobilisation of leadership influence upon the system. This is not an issue for Government alone. Local government can bring its strength in public engagement with its new powers in the health system to show that we are part of a credible change in culture. If the starting point of that new culture is to be authentic, patient-centred care, that means staring into the face of the unacceptable.
The NHS is for all of us, and we need to have complete confidence that if, or perhaps when, we require hospital care at some point in our lives, we will get care be of a high standard. I do not expect that NHS always to be able to cure me of whatever might befall me. But I do expect it to keep me fed and watered. I am not sure that the NHS will be able to extend my life. But I know full well that the NHS should not shorten it.
Mid Staffs failed when measured against my top two expectations.
It is imperative that the cultural change programme should speak to these most basic definitions of being patient-centred: to not make the mistake of over professionalising the personalised. The system and its culture have to have a human face expressed by a new-found certainty that it can meet basic human needs in a way which Mid Staffs tangibly failed to do.
For me, its the simplicity of personalised care that is the most important task - yet also the most difficult. In this increasingly complex, bureaucratic and legalistic world, it's easy to make caring for people complex. Any fool can come up with new forms, checklists and paperwork to try and make something happen or more likely, to prove afterwards that `something was done’. Appropriate, compassionate and personal care cannot, by its very definition, be prescribed in advance and captured in a glorious procedure manual. Great professionals know when to put the book down and `do the right thing(s)’ and are supported by leaders who share these values.
Leadership today means the hard work to create the space for professional staff to focus on the personal while providing political and public assurances on productivity. Dympna Cunnane and Robert Warwick, writing for the Guardian Professional site, make the case for a new approach that can face two ways to deliver both efficient, reliable administration and compassionate care.
"Organisations need to be designed with their core purpose in mind, from the outside in, which means mindful leaders who can bridge the gap..." I can not exempt myself from questioning how "mindful" my leadership is. As I write, Birmingham is preparing for a peer review, looking at how we have balanced quality, safety and dignity with the major reductions in our budget over the last three years. I question whether the £ signs have come to dominate the agenda.
More hopefully, I know how hard we have tried to balance reducing resources by a third against social care values. Birmingham's politicians are bravely struggling with a current review process that is trying to lead with core values within further diminishing resources over the next four years. The test remains whether we can make the `outside in’ balance with still less resource.
Mindful leadership would also recognise that supporting the most vulnerable of people takes a toll upon the individual. Bev Fitzsimmons at the Kings Fund suggests a need to acknowledge "the unprecedented pressure...dealing with illness and distress day in, day out."
I recently had a letter complimenting staff, where their support for a family at the time of the loss of their mother had included a manager coming to sit with them during the small hours of the night. This was rightly recognised as outstanding practice and commended by the family for the huge difference it had made to them. However big and demanding the day job, the manager had given of himself and his own time to respond to human loss.
The direct opposite is the most chilling comment in the evidence to Francis which came from the nurse who said that they had “made (themselves) immune to the sound of pain".
Practitioners who make themselves open to others make themselves vulnerable.
Some, although not all, of stress-related illness might be about, and stem from, exactly such commendable practice. I am probably not unique in being very target driven on sickness levels at present, yet mindful leadership at least pulls me up to remember that even this task is multi dimensional.
So it maybe that at the core of this complex cultural change requirement lies the multi-faceted nature of the leadership task. Great leadership is complex and multi-dimensional, where contradictions arise at every turn. We should assert this as our role, dealing with the complex so that we clear a route to the truly personalised care required at the sharp end of the business. Making the business of leadership too simple, through the application of mere targets for example, should therefore be a warning sign.
The Kings Fund suggests eight factors in securing the right culture, all of which carry their own complexity. Real cultural change will be based on an acknowledgement that leading in care systems requires a skill and competence in public sector management that should not be denigrated nor relegated to a lower level than the wealth producing management of the private sector. Public sector management has a multi-faceted nature, and the answer to whether people get great compassionate care will never come from a target or any other singleton approach.
The task of leading these great systems will need valuing and nurturing too. Dickens sought to challenge Victorian England to face its unacceptable sides. Francis perhaps is taking us into meeting an equivalent challenge for our times. It might be difficult for us to comprehend the scale of the basic cruelty revealed by the report. It might also be that perhaps none of us finds it that easy to accept our mortality, let want to consider how we might spend our final days in hospital.
There is much that leads us to want to leave such uncomfortable things in the `too difficult’ box, or to consign them to a convenient blind spot. We can seek to justify such a choice by using cultural change as too vague, too amorphous or too vast. This is not acceptable: none of us wants to picture a death foretold by a Mid Staffs experience or similar.
I came to love "Bleak House", probably because it was there for five years of my life. Its call for systems change stuck deep with the younger me. I wanted to alter the way the whole thing worked. I was intolerant of power that blocked out the possibility of better. It was that very commitment to system change that resonated with the choice of social work as my career path. Francis is a reminder of that radical inner voice, the discontent with systems that entrap people to cause pain and hurt.
I get cultural change. And I recognise that I am a part of that change. Bring it on, and bring it fast.