Whichever way you look at it, responding to Francis and the associated reports was going to be a challenging balancing act for the government – in fact, a whole series of related balancing acts.
The government needs to demonstrate that it is taking action now, while also recognising that culture change is a long haul. It needs to punish neglectful care, but demonstrate that it trusts staff to do their best. It needs to ensure accountability but not promote a blame culture. It needs clear sanctions and actions to tackle poor care, but also needs to encourage openness and honesty when poor care happens. It needs to be specific enough to set clear expectations and direction, but not to be so prescriptive as to ignore valid local differences. It needs to ensure safety data is used for management and accountability, but also owned by teams and used for learning and improvement.
These different goals aren’t mutually exclusive, but they will be worth remembering in the months and years ahead when we judge how effectively the changes set out in Hard Truths are being implemented.
And, of course, patient safety is by no means the only area of health policy fraught with different but parallel goals. We want the NHS to help us stay healthy and out of hospital, with more services available closer to home, but we’ll sign the petition on our high street if we hear that it’s our local hospital that’s going to close. We don’t want to spend any more of our taxes on the NHS, but we want it to keep giving us the best new drugs on the market. We don’t want it to be run from Whitehall, but we don’t want local control to mean that someone can get a treatment in Sheffield that someone in Leeds is denied. No wonder so many politicians think the job of health secretary is a poisoned chalice.
So has Hard Truths got it right? A detailed debate about the pros and cons could be had about each and every one of the report’s decisions. For example, the government may have been right not to adopt the recommendation that non-disclosure should be a criminal offence, but on the other hand I’m not convinced statutory protection for whistleblowers would make it more likely that staff would raise concerns. Overall, any actions from national bodies can only ever be a third line of defence against poor care. The real action will have to come from boards and frontline staff. On the whole, however, I think that Hard Truths navigates a difficult course well, and, thanks partly to the recommendations and ambitions of the reports it responds to, it is full of well-judged and important changes.
The last Labour government used the evidence on how to improve safety and quality to inform the 2008 Darzi review. This government has rediscovered the importance of that evidence in 2013. Let’s hope that future governments concentrate on it from day one.
The elephant in the room is the coalition government's radical agenda to privatise as much of the NHS as it can. By driving through the radical changes enshrined in the Health and Social Care Bill against sustained and comprehensive opposition from right across the political and disciplinary spectrum, the coalition government is in large part responsible for making it harder - much harder - to achieve safe, high quality patient care in an integrated, collaborative and cost-effective national health service. As an NHS patient and as a health services researcher, I can't take anything the coalition government says on the NHS at face value. For me, those are the "hard truths".
we need to understand why there is resistance to being open and honest in the NHS when errore and mistakes are hidden or concealed . Performance data only as good as the person inputing the data.
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