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Sir Bruce Keogh’s review of the quality of care and treatment provided by 14 hospital trusts in England was hard-hitting about the need for change and supportive for those who will need to drive it. This is a delicate and subtle balance, but an important one if the NHS is to achieve the openness that Keogh calls for.
However, the government’s response to the proposals and, in particular, the tone of Jeremy Hunt’s response to the Keogh Review in the House of Commons in which he promised to ‘tackle and confront abuse, incompetence and weak leadership head on’, risks threatening the openness urged by the Review.
So how can boards foster openness in their organisations? The most pointed accusation by Keogh is that boards are not learning from feedback from patients. Whether organisations are actively seeking different ways to get feedback and learn appears to be a more important indicator of quality outcomes than the level and type of complaint. Why is this? Because cultures of curiosity and openness suggest an organisation is confident enough to hear complaints and has the spirit of learning and innovation needed to correct problems.
Creating cultures in which staff engage with complaints from patients seems difficult to achieve in practice. A chief executive speaking at The King’s Fund recently said ‘letters to patients are too often a smokescreen, a carefully worded response and a displacement from the organisation looking under the surface’. As an aside, it is a governance risk when boards don’t know about the culture(s) in their organisations.
What can improve our ability to listen? We hear criticism more easily when we trust our surroundings; when we don’t, our behaviours are defensive and avoiding. When we open ourselves up to scrutiny we need to trust that we will be supported and get a proportionate response from those scrutinising us. Future regulation will need to be mindful of this as it introduces a new focus on culture and what it means to be ‘well led’.
Constant criticism of NHS leadership doesn’t help boards to be transparent. Political rhetoric that the role of non-executives and executives is to ‘challenge’ has probably done more good than harm and kept the board’s focus on scrutiny. But challenge that is poorly delivered achieves the opposite: it ruffles feathers and causes colleagues to ‘back off’, reducing trust at board level.
Boards need stability to have good discussions. Constant changes in leadership make it impossible to embed a single strategy. Losing and de-motivating good people won’t help either. Rumours around the lack of internal candidates for a replacement to Sir David Nicholson suggests that senior leaders are turning their backs on the top jobs.
Board leadership must be treated with care. Jeremy Hunt’s Commons response to the Keogh Review used strong language about incompetence and weak leadership. For some NHS organisations this criticism may be justified, but it does send signals that leaders will be scrutinised, named and shamed. It would be a shame if, as a result, some of the policies that boards may wish to get underway to increase their openness may be halted directly or indirectly. Creating conditions that mean that boards retreat from positions of greater openness with staff, with one another and with patients would be a backwards step.