What is candour without accountability?
Authors: Kamran Abbasi
Journal: Journal of the Royal Society of Medicine (2013)

What is power without accountability? What is professional life without candour, the word of the moment? These are just two of the many questions emerging from the Francis report into events, deaths and mismanagement at Mid Staffordshire NHS Foundation Trust. The report is expected to be a lightning rod for change in the NHS but like the inquiry into the deaths from paediatric cardiac surgery at Bristol Royal Infirmary, which recommended change in NHS culture over a decade ago, the Francis Report is in danger of falling short of its ambitions.

The report is a numbing account of the misguided management culture at Stafford Hospital; of failures in compassion and unacceptable care delivered by clinical staff. Doctors and nurses face censure by their professional bodies in relation to events at Mid Staffordshire trust.1 Considering the scale of failure at the hospital, even this level of clinical accountability may be too little. Meanwhile, no senior manager or executive at the Trust, or at higher levels in the NHS, currently faces comparable disciplinary action. The professional regulatory bodies of medicine and nursing are much maligned, but no equivalent body exists to hold managers to account.

Delivery of care is a process and, like any process, failures are those of the system—this is a message drummed into us well enough. Managers are trained to manage widget factories and engineer manufacturing processes. But healthcare doesn't produce widgets, it is meant to improve health. Improving health comes as a result of managing many complex production processes that managers may not have the clinical skills to grasp. When people running a business, because that is what we are told healthcare has become, do not understand the fundamental production processes in that business, the system is at risk of going awry. Foundation status and cost control matter nought to patients and their biological mechanisms.

A no-blame culture encourages honesty, whistle blowing and candour. Blame and accountability, however, are separate concepts; ‘no blame’ does not mean ‘no accountability’. For a failure on the level of Mid Staffs, a senior manager, executive or politician—probably several—must take responsibility. By the time you read this somebody may have held their hand up, but this omission in the Francis report is a difficult one to rationalise.

In the case of Mid Staffs and the Francis report, where does the buck stop? The leading executives of the Trust, the regulators overseeing the Trust, and the senior mandarins of the NHS, are ultimately responsible for patient safety. Like colleagues elsewhere in the NHS who wield real power, they were caught up in the propaganda of the time, which promoted a ‘NHS market’, even a NHS supermarket, and a commercial nirvana of Foundation Trust status.

Neglect at senior level permitted a calamity for patients and families at Mid Staffordshire. What, then, is power without accountability? At the very least, what is power without honour?

The primary purpose of the General Medical Council and the Nursing and Midwifery Council is to protect patients. The Francis report is explicit in how the role of managers can contribute to patient safety and harm. The logical extension of society's rightful desire to protect patients must be that oversight of health service managers is comparable to oversight of doctors and nurses – be that by regulation or an alternative better system. Managers unprepared for this level of scrutiny and oversight may be best running a business with less serious consequences. Doctors, nurses, and managers – all responsible for patient care and safety – must be similarly accountable for delivery of healthcare.