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22 April 2013

It’s not just nurses – ministers are also trapped in a bureaucratic cage

With the Royal College of Nursing claim that nurses are “drowning in a sea of paperwork”, now seems a good time to re-visit the Francis Report. You remember that, don’t you? It only came out in February, documented the horrific neglect of patients at Stafford Hospital and then swiftly disappeared from the headlines – as if it didn’t really matter.

Needless to say, the failures of the NHS do matter – not least because they’re hardly confined to a single hospital. The Francis Report also matters, because the proposed policy response is profoundly misconceived – and likely to only increase the bureaucratic load on nurses and doctors.

The point is well-made by John Seddon in an article on his Vanguard site: 

  • “The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.”

“The wrong thing righter” sums up so much about the way that public policy is made and implemented in this country. It speaks volumes about the reluctance of those in authority to rethink – or even think about – the nature of the systems they assume they’re in control of:

  • “The 1,782 page Francis report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.”

When the flaws in our public (and private) sector institutions are so fundamental, the refusal to dive deep means that doing the wrong thing righter is the only option.

This is why any policy response based on the Francis Report will be undone by its contradictions:

  • “The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.”

So what should Jeremy Hunt do instead? This is John Seddon’s answer:

  • “The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare?”

This, unfortunately, is where Seddon doesn't quite get it right – not because NHS managers shouldn’t have to justify their existence, but because he doesn't acknowledge what would happen next. 

Upon receiving such an order from the Health Secretary, the NHS bureaucracy would move into overdrive, felling whole forests to provide the paper on which to testify to the brilliance of its actions.

Faced with a data dump of this magnitude, the health secretary would have no choice but to turn to his civil servants – and/or to another committee of the great and the good. And with grim inevitability, both the officials and the worthies of the establishment would pronounce themselves broadly satisfied with the workings of established officialdom.


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