Governance Crisis at Mid Staffs NHS

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Table of Contents

Introduction
History of governance crises at Mid Staffs
Analysis of Issues around Governance and Leadership
Conclusion
Reference List

Introduction

In England, the National Health Service (NHS) is in charge of offering high quality free medical care and regulating most of the facilities for health care provision. There are thousands of people working in the organisation. They are the core resources that enable NHS to achieve its objectives. In addition, the quality of service delivery by any particular unit of NHS or the entire national organisation depends on the delivery care to patients (The NHS Confederation 2008). Thus, when patients complain of poor services in hospitals, they directly imply that NHS is not performing its duties as prescribed in its mandate and organisational objectives (Silvester et al. 2004).

It is hard to benchmark quality delivery and stakeholder satisfaction in health care delivery. One reason for this is that health care is a continuous service and cannot stop for the sake of making a review and a report. Secondly, there are different aspects of health care interaction with different stakeholders. These aspects occur simultaneously, such that it is possible to highlight a line of service delivery, but impossible to isolate it from influences of other lines of service delivery (Silvester et al. 2004).

This paper provides a history of governance crises at Mid Staffordshire, UK, also referred herein as Mid Staffs. The case is about health care governance failures measured by minimum patient safety and quality standards. The paper also reviews the principles of governance and theories of leadership in discussing the case and recommending a governance solution.

History of governance crises at Mid Staffs

Parliamentary reports of the health conditions between 2005 and 2008 for Mid Staffs hospital services were negative. They highlighted the governance problems of the board in charge of the service delivery. As a remedy, changes happened to replace the board with the Mid Staffordshire General Hospital NHS Trust. Before the appointment, the Trust went through necessary scrutiny by the Department of Health and the local Strategic Health Authority. Other public committees were also involved in the vetting process. They rated its risk management abilities and checked for any systematic failures of the trust. There were none identified. The Trust’s conduct and capabilities were above board, based on the common review standards (UK Parliament 2013).

It was in the Trust’s management and leadership that troubling evidence was found. High mortality rates highlighted by a group of patients indicated that hospitals were not taking care of patients as they were supposed to. The blame lay with the Trust’s management (UK Parliament 2013).

After a parliamentary inquiry, there was evidence to show that the external organisations that were in charge of overseeing the operations of the Trust did not detect anything wrong, when clearly there was something wrong happening. There was a systemic failure promoted by the blinded review and oversight given by organisations, such as the Healthcare Commission. The failure was at the national and the local oversight levels (UK Parliament 2013).

From conventional practices of health care, which are in line with best practices of quality management, multiple oversight opportunities are supposed to ensure that there is enough information collected about the quality of service delivery. The information should then be the basis for future regulatory decisions and policies to increase benefits to patients and other stakeholders throughout the country (UK Parliament 2013; Genovese 2014).

The following were the recommendations adopted to improve the delivery of health care as a public service after a parliamentary inquiry into appalling health care status at Mid Staffordshire. First, there would be an examination of what commissioners, supervisors, and regulatory bodies did or failed to do to perpetuate the failure of quality service delivery (UK Parliament 2013). Secondly, there would be an identification of recent changes to improve the situation, which would include the agreement between the Monitor and the Care Quality Commission so that the processes of identifying hospitals became open. There would also be a review of the necessary improvements needed in the scrutiny mechanism and the availing of resources to support governors in charge of the Foundation Trust (Silvester et al. 2004).

The disaster happened in an NHS acute hospital provider trust. This is one of the trusts that are supposed to have a very high level of quality threshold, in both health care and governance standards (UK Parliament 2013). It is also worthy to note that the regulator of health providers in primary care is the same for both public and independently funded care providers. Thus, the policies implemented by the regulator are aimed at providing a common working regime for both kinds of providers (WHO 2014).

In the Mid Staffordshire hospital, patients and their families felt excluded from the process of care delivery. They could not take part in the patient’s care, even though they were the most likely to suffer from the loss of patients’ lives (UK Parliament 2013). The Community Health Councils (CHCs) worked well, but their replacements after reorganisations in the health care industry became ineffective. Unlike the CHCs, which were professional bodies, their replacements were individual volunteer groups that lacked a formal channel of collection and expression of views to implement regulations and enact policy changes (UK Parliament 2013).

There were multiple routes for patients to feed comments into health services and seek accountability, but the routes were ineffective in the Mid Staffordshire case (UK Parliament 2013). In addition, most of the feedback to the health care service organisations or the relevant public management watchdogs like parliament went unheeded, partly due to the lack of expertise and partly due to the lack of a defined issue resolution framework that would be effective for the case (Chau & Kao 2009).

Analysis of Issues around Governance and Leadership

Key principles of governance and their relation to the case

Governance relates to the way individuals or a group works collectively with the goal of ensuring that an organisation remains legally and morally upright. Usually, the group is legally constituted as a board or a trust to perform the governance tasks. Therefore, the board in such as health care organisation would be accountable to the constituents for the fulfilment of the organisation’s mission (Calder 2008; Nwagbara 2010).

The governing board is different from the managing group because of two major issues. First, the governance team establishes policies for its operations, such as rules for board meetings. Secondly, it focuses on strategic issues of running the organisation effectively, rather than concentrating on routine matters. In comparison with the case, it implies that the Trust put in charge of handling the hospitals in Mid Staffordshire was in charge of coming up with appropriate ways of handling its affairs in ensuring its success. Secondly, it was to concentrate on serving the strategic interest of health care facilities under its regulatory authority. Thus, it should have been keen on checking for the effect of policy and general conduct of hospitals. In the case of health care, the most basic result is the patient outcome after hospitalisation (The NHS Confederation 2008).

The effectiveness of the board or the Trust lays in the skills and experiences of its constituent members and any available oversight. Given that the board has self-governance privileges, it has to embrace regular monitoring and evaluation of its own performance and evaluate the individual contribution of all of its members (Scouller 2011).

When board members have extensive experience, they can make decisions concerning the strategic directions of their organisations (Strang 2005). However, extensive experience also fixes the particular member to the intricate details of day-to-day management of the organisation and can be a cause of extensive interference with management activities (Calder 2008). Corporate governance code advises boards to remain independent of management duties. At the same time, it is important for boards to have a long-term view of the organisation. It is not appropriate to rely on short-term goals, as they can fool the board into thinking that it is heading the organisation in the right direction, when it is not (Health Resources and Services Administration 2010).

In the case of Mid Staffordshire, the governance Trust was keen on meeting the necessary benchmarks for quality management, as set by its oversight authority. However, the results of its governance show that it must have neglected the need to look beyond results and considered their organisational implications in the end (Bamford & Chatziaslan 2009). If the Trust had this strategic concern, it would realise that missing some key indicators of quality performance would eventually hurt the organisation’s mandate of delivering quality service, measured in terms of patient outcomes from hospitals (Bernad 2014).

Boards or governing trusts need diversity in their membership to prevent the effects of groupthink (Chahal et al. 2008). Principles of good governance call for leadership, which implies the provision of direction, mentorship, oversight, advice, and analysis (Chahal & Eldabi 2011). The governance team must also have the capacity to meet its obligations, which entail the right mix of skills, experiences, and independence to avoid problems highlighted above and those witnessed in the Mid Stffordshire case (Bean 2009; Wildes 2008).

Above all else, accountability is important, not just for the sake of filling out reviews that are long forgotten after the process. Accountability in this case is about meeting the needs of stakeholders in a regular interval, based on a fair, balanced, and understandable assessment (Martin et al. 2013; Ogbonna & Harris 2011). In comparison to the case, the Trust at Mid Stffordshire hospital case was accountable. It answered to several local scrutiny bodies and was subject to reporting to the NHS. However, the accountability was not reflective of the Trust’s comprehensive purpose, which was to ensure that patients received high quality medical care (UK Parliament 2013).

Another principle of good governance is sustainability. The governing team needs to create value and allocate the value fairly and in ways that service both short-term and long-term needs. It has to reinvest and distribute gains to all stakeholders. The Mid Stffordshire Trust needed to look at the patients’ welfare, their families, the workers at the hospitals, the community interest groups concerned with health care, and any other group qualifying as a stakeholder. Ignoring the families of patients was not a sustainable way to run the Trust’s affairs.

Lastly, integrity as a principle calls for fairness and transparency, as it is the basis of having oversight authority. As much as the Mid Stffordshire Trust answered to its appointing authorities about its work, it failed in the integrity test because it did not answer to all the stakeholder groups. It did not learn about the interests of the stakeholders and come up with feedback reports to show what it was doing to address their concerns. This explains why, despite reporting to the NHS as standard practice, appalling health care results persisted in acute level hospitals under the regulation of NHS in Mid Stffordshire.

Theories of leadership and their relation to the case

Governance requires leadership, thus it is important to review the theories of leadership to build an understanding of a governance case and to come up with best practice recommendations effectively. Leadership theories fall into four main groups, namely trait theories, behavioural theories, contingency theories, and power and influence theories. The first one looks at the characteristics of a person, which make him or her good leader. Given that they are based on personalities, the theories would be most applicable when reviewing the conduct of individual Trust members independently and assessing their contribution to the overall achievement of the trust. At the same time, it can be useful for looking at the Trust as a unit with human characteristics, such as discipline and empathy, to review its performance.

Behavioural theories are concerned about the actions of leaders and can be broken down into autocratic leadership behaviours, democratic leadership behaviours, or laissez-faire leadership behaviours. The background discussion of the Mid Staffordshire case shows that the Trust’s leadership style was autocratic. The Trust made decisions, but it did not rely on input from other stakeholders. This method of leadership was good because it would allow the Trust to avoid associated bureaucracies of dealing with different stakeholders when coming up with policy changes at its level of jurisdiction over hospitals.

Although a particular style of leadership is ideal for particular situations, not all styles would be appropriate when used exclusively. Thus, a combination of different styles is important with regard to both personality traits theories and behavioural theories of leadership. A salient issue with the application of leadership is that there should be adequate knowledge of situational parameters and the application of the correct style to achieve a given outcome. Review and feedback help to keep the leadership grounded on the right strategy at all times.

In light of the above consideration about the absence of good leadership traits or behaviour, the contingency theories step in to resolve the impasse and provide an applicable solution. The theories first assert the unavailability of a correct leader. Therefore, instead of explaining the right leader, the theories provide guidelines for leadership qualities that are appropriate for a given situation (Harris 2009).

Stakeholder interests and knowledge, as well as available information inform the analysis of the right leadership style. A given style would suit quick decision making, while another would remain appropriate for lengthy deliberations and the need to find common grounds. Examples under the contingency theories’ category are the Hersey-Blanchard situational leadership theory and the path-goal theories (Lussier & Achu 2010). As the names suggest, each tries to find an accommodative solution for leadership to suit the capabilities of leaders and the interests of the organisation, as prescribed by stakeholders (Fyke & Buzzanell 2013).

The path-goal theory identifies many potential ways to a goal, but it realises that only one will suit the stakeholders’ interest. Therefore, after acknowledging an interest, leadership has to invest in the identification and pursuit of the right path to the intended goal. From the Mid Staffordshire case, it is apparent that the Trust was pursuing a different path to the goal of quality health care delivery (Harris 2009). It failed to clear away obstacles to improve performance. As discussed earlier in the paper, the biggest obstacle for the Trust was the disregard for information from the patients and their families as the key stakeholders (Lussier & Achu 2010).

Leaders may need to use power and influence to enforce changes (Natale, Sora & Kavalipurapu 2004). Boards of governance have the necessary power to show the direction of their organisations. That is why they are held responsible for the achievement of the organisational goals (Duff 2013). Based on the power and influence theories, appropriate leaders use the power created by legitimacy, reward, or coercion, in addition to the power created by expertise and referrals. As the mandated authority for delivering health care in Mid Stffordshire, the Trust had to become transformative, instead of just complying with routine steps of a governing board (Daft 2011; Deering, Dilts & Russel 2003).

A fundamental failure in the leadership team at the trust was the failure to consider the motivations for different routines and to evaluate their relationship with the delivery of stakeholder interests (Eisenbeiss 2012). It should have realized that routine reporting and scrutiny were meant to limit the repeat of known governance problems (Beerel 2009). However, the Trust did not pre-empt future problems that were unique to the present knowledge. It should have, instead, focused more on collecting feedback and increasing its knowledge of the organisation under it to not only serve as the leading authority in the health care quality delivery matter, but to also inform its strategies to make better improvement decisions (Buschman 2013). According to the case, the local general practitioners only expressed substantive concern when there was external scrutiny, yet this should have been a normal behaviour had the Trust criticized its own leadership (Martin et al. 2013).

Recommendations for the development of governance and leadership in Mid Staffs

Every leadership theory when applied in isolation will seem to fit the Mid Stffordshire case. However, after looking at the case parameters, the following is the approved leadership proposal that should ensure a high and appropriate governance system is in place. It is appropriate to look at situation-independent qualities of leadership as fundamental causes of the problem, given that there were adequate checks and balances in place and still the deficiencies of the health care system at Mid Stffordshire became known. It is also important to look beyond personalities, as the Trust and the overseeing authorities provide leadership based on systems and consist of diversified membership backgrounds (Bertocci 2009).

The eligibility criteria for the Trust were loosened, which made it possible for a relatively less competent team to take over governance of the Mid Stffordshire hospitals. Had there been a thorough scrutiny of the minimum patient safety and quality standards, there would be enough evidence to deny the Trust the governance mandate over hospitals. The above gaps point towards an institutional leadership failure caused by insufficient criticism. A reactive leadership approach would, therefore, suffice to remedy the situation.

The path goal theory recommends supporting leadership, where the creation and improvement of relationship between leaders, followers, and stakeholders is the main goal. However, for unstructured projects, such as the one of leading hospitals in care delivery as a mandate of the Trust in the Mid Stffordshire case, directive leadership would be appropriate because it communicates goals and expectations.

Judging from the notes about the formation of the Trust, it is apparent that the team had adequate experience in health care matters for it to pass the vetting process for appointment. A participative leadership form would ensure that the Trust works closely with the workers in hospitals to identify problems that would be overlooked by the systemic criteria of evaluating work performance in the hospitals. It would work closely with the management to understand arising problems they face that would be unique to Mid Stffordshire or a particular hospital.

Therefore, this paper recommends a governance system that follows the path-goal theory of leadership, as it will remain responsive to arising problems and provide room for internal scrutiny about the mechanisms currently in use.

Conclusion

The basis of this paper was to discuss the Mid Stffordshire hospital health care delivery failure case and then use that as a basis for coming up with an appropriate advice on appropriate ways of reforming governance. To achieve the objective, the case reviewed the principle of good governance and literature on leadership theories. As it did so, it maintained a relationship with the case by linking theoretical underpinnings with the observable characteristics from the case. Lastly, the paper recommended the path-goal leadership system as the best for governance for its responsiveness and situation independence, which make it applicable to the governance of institutions with varied functions like the NHS.

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