Speaking of the public response to the deaths of children at the Bristol Royal Infirmary before 2001, the BMJ commented that the National Health Service (NHS) would be ‘all changed, changed utterly’.1 Today, however, two inquiries by Robert Francis QC into Mid Staffordshire NHS Foundation Trust suggest nothing changed at all.2 In Bristol, some 30–35 babies may have died from their treatment. In Mid Staffordshire, it is thought that between 400–1200 died as a result of substandard care. The stories of indifference and neglect are harrowing. Apart from the failures of clinical care, patients were not fed or given water, they were not taken to the toilet, left to relieve themselves in their beds and then not cleaned, call bells were not answered, and staff, patients and relatives in the wards felt intimidated. Volume 2 of the first Francis report should be compulsory reading for all clinical undergraduates for its depiction of clinical heartlessness. Surely, stories like this are not representative of the NHS as a whole.3 Yet neither are Bristol and Mid Staffordshire isolated incidents. In 2011, the Health Services Ombudsman, Mrs Ann Abrahams, reported on the care of elderly and frail patients in the NHS. She foundan attitude—both personal and institutional—which fails to recognise the humanity and individuality of the people concerned and to respond to them with sensitivity, compassion and professionalism. The reasonable expectation that an older person or their family may have of dignified, pain-free end of life care, in clean surroundings in hospital is not being fulfilled. Instead, these accounts present a picture of NHS provision that is failing to meet even the most basic standards of care. These are not exceptional or isolated cases. Of nearly 9,000 properly made complaints to my Office about the NHS in the last year, 18 per cent were about the care of older people… 4

The Care Quality Commission (CQC) reported ‘time and time again… cases where patients were treated by staff in a way that stripped them of their dignity and respect. People were spoken over, and not spoken to; people were left without call bells, ignored for hours on end, or not given assistance to do the basics of life—to eat, drink or go to the toilet.’5 In 2007, the Healthcare Commission found many complaints from patients and relatives about the quality of nursing care. These primarily related to patients not being fed, call bells not being answered, patients left in soiled bedding, medication and nutritional supplements not administered, charts not completed, poor hygiene practices, and general disregard for privacy and dignity. Not only were they distressing, but in the case of seriously ill patients, poor care related to hygiene, medication, nutrition and hydration may have adversely affected the outcome for the patients.6

Why is there such tolerance of poor clinical standards? The General Medical Council (GMC) insists that doctors ‘must protect patients from risk of harm posed by another colleague's conduct, performance or health.’7 Yet, it acknowledges that ‘between 120 to 150 doctors must have known something was going badly wrong at Stafford Hospital yet few raised concerns through the proper channels’.8 We need a better understanding of the culture that can lead to these outcomes and how best to enhance it. We discuss the findings of these and other reports and consider whether (1) attention should be devoted to managing individual behaviour, or (2) we should manage the systemic influences which predispose hospital staff to behave in this way. Alternatively, (3) should we look further afield to cognitive psychology to better understand how clinicians and managers make decisions?

Managing individual behaviour

Are failures of this kind primarily the responsibility of individuals? One response is to introduce an individual duty to react by reporting poor standards of care. In 1996 the Nolan Committee commented on the benefits of staff raising concerns about public services. It said:Encouraging a culture of openness within an organisation will help: prevention is better than cure. It is striking that in the few cases where things have gone badly wrong in local public spending bodies, it has frequently been the tip-off to the press or the local Member of Parliament—sometimes anonymous, sometimes not—which has prompted the regulators into action. Placing staff in a position where they feel driven to approach the media to ventilate concerns is unsatisfactory both for the staff member and the organisation.9

Duties to report have been introduced in professional practice and law. How successful have they been? Let us consider each in turn.

Professional guidelines

Extensive professional standards stipulate for selfless conduct in circumstances where the safety of patients may be at risk. Good Medical Practice continues:… If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. This means you must give an honest explanation of your concerns to an appropriate person from your employing or contracting body, and follow their procedures.10

Concerns about patient safety or the performance of clinical colleagues can come from patients, colleagues, critical incident reports and clinical audit. The GMC states: ‘If you receive such information you have a duty to act on it promptly and professionally.’11 If appropriate local systems do not exist, or do not resolve the problem, ‘you should inform the relevant regulatory body.’ The Nursing and Midwifery Council (NMC) Standards of Conduct demand comparable requirements from nurses and midwives.12 Doctors with managerial responsibilities are subject to Management in Health Care: the Role of Doctors which confirms: ‘You continue to have a duty of care for the safety and well-being of patients when you work as a manager. You remain accountable to the GMC for your decisions and actions even when a non-doctor could perform your management role.’13 Early warning systems must exist to alert managers of concerns about clinical performance, including concerns about decisions made at board level which could place patients or the community at risk of serious harm.14 In these circumstances, medical managers must have their objections formally recorded.15 In addition, in a rare example of a duty to inform the patient, or their relatives, that things have gone wrong: ‘If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects.’16

Clearly, these exhortations have had little impact. One explanation for the lack of clinical willingness to report is the belief that there's no point in doing so because nothing will change. The British Medical Association's Speaking Up for Patients survey found that although almost 70% of consultants and staff grade specialists said they would express concerns to a responsible hospital employee, most expected nothing would happen. Most disagreed with the statement that ‘concerns raised will be acted upon’.17 The same point was made in 2000 when the Inquiry into Rodney Ledward considered the failure of hospital managers and clinicians to respond to well-recognised concerns about a consultant gynaecologist. It found no concerted effort was made to confront the problem and patients suffered foreseeable harm as a result.18

An analogous regime applies to NHS managers. The Code of Conduct for NHS Managers,19 was published in response to the Bristol Report. It states that it ‘should be seen in the wider context that NHS managers must follow the Nolan Principles of Conduct in Public Life ie, selflessness, integrity, objectivity, accountability, openness, honesty, leadership’.20 The Code requires of NHS managers that: ‘I will make the care and safety of patients my first concern and act to protect them from risk,’ and that ‘anyone with a genuine concern is treated reasonable and fairly’.21 Oddly, it does not apply to all NHS managers, but is restricted to ‘Chief Executives and Directors …(and) any other senior managerial posts, ie with levels of responsibility and accountability similar to those of Director-level posts....’22 Following the first Mid Staffordshire report, the National Quality Board's Review of Early Warning Systems in the NHS23 recommended a system in which responsibilities were cascaded throughout the NHS, from ward level up to the Secretary of State. Thus: ‘If a clinical team or manager is concerned about their performance or the outcomes of care provided and is unable to address the issue quickly and effectively, they should tell the medical/clinical director or director of nursing.’ Responsibility should pass from wards, to clinical directors, boards, NHS commissioners, the NHS Commissioning Board and ultimately the Department of Health.24

None of these duties have impinged much on professional behaviour. The Department of Health does not keep central records about the use of the Code of Conduct for NHS Managers. Individual cases are for each hospital trust to determine. In the light of these reports, one wonders whether anyone has ever considered if it is working and whether such a review would suggest patterns of conduct which required a response.25 The answer, it seems, did not command sufficient priority to merit serious attention.

Managing systems

Should greater emphasis be placed on managing systems? Let us consider the managerial and regulatory structures surrounding Stafford Hospital. The government wanted hospitals to become Foundation Trusts capable of operating within strict budgets. The SHA focused on finance at the expense of care. The hospital board complied with the SHA's demands blind to the enormity of what was happening, and doctors and managers were detached from patients. What happened to the regulatory safeguards designed to manage these risks? James Reason's explanation proposes the ‘Swiss Cheese’ model of organisational accidents in which each regulatory ‘defence’ to failure is illustrated as a slice of cheese,36 each containing holes that may change in size and shape depending on the circumstances and culture prevailing from time to time. Accidents occur when the holes line-up ‘to permit a trajectory of accident opportunity’37 so that the clinical risk can pass through each regulatory ‘slice’ undetected. An overemphasis on financial ‘defences’ may neglect clinical risks and vice versa. This illustrates the regulatory challenge for clinical standards in Mid Staffordshire. The focus on finance encouraged holes in each of the regulatory ‘slices’ so that the most egregious clinical failures failed to come to regulators’ attention. As Francis found, ‘undue comfort was taken from the assumption that others had responsibility in terms of quality.’38 We need a much better understanding of the processes that drive the risk of regulatory failure. We consider (a) the neutralising force of targets and disincentives (b) the disadvantageous position of clinicians in managerial roles.

Cognitive psychology: heuristics and biases

Let us now turn to the extent to which psychology may help to illuminate the imbalance of influence between clinicians and managers by the theory of heuristics and biases. The dual process theory of thinking illustrates the way we process information.43 System 1 thinking operates fast and intuitively; it seems to be automatic, unconscious and requires little or no effort. By contrast, System 2 seems to be an explicit, controlled, conscious process which requires more effort and is more logical and deductive. It is probably more reliable than System 1, but has the disadvantage that it involves extensive periods of thought and reflection. Clinical training emphasises System 2 thinking.44 However, time-consuming reasoning of this nature is neither possible nor necessary for every decision. Thus, we usually rely on System 1, which is inductive, instinctive, not based on reason and probably reflects our personal experience and ‘hunches.’ Because this system is based on experience, it is reasonably reliable and has the significant advantage of speed over System 2. It enables us to make decisions rapidly and is an endemic component of human decision-making.

Inevitably, System 1 thinking is prone to greater error. Kahneman and Tversky have shown how the mistakes we make do not occur at random. Human reasoning habitually incorporates heuristics and biases, which predispose us all to similar patterns of departure from well-informed, deductive, rational analysis.45 For example: (a) we place disproportionate weight on avoiding adverse risks by comparison to the prospect of benefiting from a similarly weighted benefit (referred to as ‘Prospect Theory’). (b) We place disproportionate weight on risks of which we have recent experience even if they are not representative of the overall level of risk we face (Recency Bias). (c) We interpret events within our own particular frame of reference which others may understand in a wholly different way, depending on our ‘framing’ of the issue.

This may help explain the apparent want of clinical compassion and lack of humanity discussed above. For example, in a hospital ward setting, these ‘frames’ are often narrow, or ‘patient focused,’ whereas the managerial frame is likely to be system focused. Similarly, NHS targets may unintentionally encourage managers to focus on league tables in a ‘defensive’ way, instead of patient care. The pressure imposed on Mid Staffordshire NHS trust by the SHA to achieve the financial targets necessary to qualify for foundation trust status may be an example. Using Kahneman and Tversky's model may explain how top-down pressure inclined managers to place disproportionate weight on avoiding the risk of regulatory sanction. Since the ‘the terror of targets’ was an ever-present threat, managers avoided adverse risk to themselves by ensuring compliance. This may be understood as a rational, even normal, response. As Woodmansey says of Mid Staffordshire, ‘While many poor judgements were made and the need to blame is entirely understandable, it is important to recognise that nobody who worked at Mid Staffordshire Foundation Trust came to work with the intention to do harm.’46 However, the ‘frame’ to achieve Foundation Trust status may have inclined managers to interpret their function within a consequentialist framework that looked to end-results, but appeared indifferent to the needs of patients. The same logic applies to Stoke Mandeville and Maidstone and Tonbridge Wells hospitals, where, as we saw: ‘managerial imperatives were given higher priority than the control of infection’.

If this is understandable with respect to managers, how can we explain the neutrality of clinicians in the process? For example, it may explain why managers respond to targets in a way clinicians regard as disproportionate, but if managers were under pressure in one direction, why were clinicians not equally opposed in the other? Why were clinicians so mute?47 Again, Kahneman and Tversky may assist us. First, we have discussed the challenge to the clinical voice in ‘complex’ reasoning. Arguably, complex, or non-linear reasoning involves greater recourse to System 1 (intuitive) thinking; it has to weigh and balance incommensurable alternatives which are often difficult to compare directly. By contrast, the clinical voice specialises in ‘complicated,’ System 2 (rational) type reasoning. Yet, strictly in their professional role, clinicians may have less training and experience with System 1 and consequently be at a disadvantage in discussion and argument. This suggests that the deductive and analytical strength of their System 2 training may be a disadvantage when clinicians debate with managers involving complex decisions.

Once the clinical board member adds their endorsement to board-level decision-making, the institutional ‘framing’ of decision is cemented and may further undermine clinical concerns. This may result in clinicians experiencing ‘cognitive dissonance,’48 where the individual is subject to conflicting ideas. Dissonance is unpleasant. We are naturally motivated to reduce or eliminate it and seek to achieve consonance by ‘dissonance reduction.’ Cognitive dissonance theory suggests that a powerful incentive to maintain cognitive consistency can give rise to irrational and sometimes maladaptive behaviour. As we noted in the Review of Paediatric Cardiac Surgery in Oxford, some doctors ‘would not consider raising this as a SUI and cannot see how it would meet SUI criteria.’ A doctor at the first Mid Staffordshire Inquiry spoke still more graphically:If you are in that environment for long enough, what happens is you become immune to the sound of pain….You cannot feel people's pain, you cannot continue to want to do the best you possibly can when the system says no to you….49

Generalisations are not possible in respect of all clinicians, as the consistently excellent performance of some of the wards in Mid Staffordshire hospital throughout this period confirms. Nevertheless, there is a risk of clinical attention being diverted from individual patients toward more recondite notions of, for example, aspiring to become a foundation trust, cost-effective care or managing the impact of budget cuts. Some clinicians are likely to be at greater risk of this psychological process than others. Clearly, an unhappy grouping of clinicians predisposed to this response in a single unit may have disastrous consequences for patients. In response, the Francis Report recommends better nurse training, education and development on delivering compassionate care and a focus on recruiting those with ‘appropriate values, attitudes and behaviours, the ability and motivation to enable them to put the welfare of others above their own interests’.50 Exactly, how these characteristics should be measured and assessed presents its own challenges.

This analysis of individuals also applies within institutions. The effectiveness of regulation itself is subject to bias. If the paramount organisational need is to save money, then regulatory defences focusing on other objectives will come under stress. In this way, organisations themselves are susceptible to bias in the sense that our psychological predispositions may be transferred to the culture of the institution. By analogy, System 1 thinking also occurs at an organisational level, with all the conformational biases this implies. Only if the organisation analyses the information presented to it, and subjects it to System 2 thinking is it likely to recognise areas of dysfunction. Let us apply this to Mid Staffordshire. The hospital was not a High Reliability Organisation (HRO).51 Weick and Sutcliffe describe a HRO as one which is able to: track small changes, resist over simplification, remain sensitive to operations, maintain capabilities for resilience and respond to shifting locations of expertise. They argue that ‘HROs encourage reporting of errors, they elaborate experiences of a near miss for what can be learned, and they are wary of the potential liabilities for success, including complacency, reducing margins of safety and the drift into automatic processing’.52Clearly, the culture prevailing in Mid Staffordshire made excellence of this nature unlikely.

Changing NHS culture: whose agenda?

Competing ‘agendas’ are at work in the NHS. For example, in 2001, the Bristol report said of government that it makes claims for the NHS ‘which (are) not capable of being met. The public has been led to believe that the NHS could meet their legitimate needs, whereas it is patently clear that it could not’ and then it blames everyone else for failure.53 Similarly, regulatory and managerial culture may be ‘captured’ by government and disabled from exercising its functions properly. And clinicians may dilute their Hippocratic commitments, ignore systemic problems and conceal failures. If we ask which party in the NHS has no particular agenda, the answer is patients. Patients want an honest, transparent and candid system. Yet the patient's voice is strikingly absent in the circumstances that have led to these reports. As patients, we are equally susceptible to heuristics and biases. We may ‘frame’ our perceptions in the mistaken belief all is well. Nevertheless, had patients in Mid Staffordshire been encouraged to air their concerns in a way that was visible to others, poor practices are unlikely to have persisted. Although the NHS has established regulatory institutions like the Healthcare Commission, Care Quality Commission and Monitor to manage the NHS from the top-down, less attention has been given to listening to patients from the bottom-up. Since the abolition of Community Health Councils in England, successive governments have diluted and destabilised the local voice in the NHS, although none explained why. More sensitive statutory bodies are required at the local level to provide this role.

Also, if online websites can aggregate consumer ratings of hotels, surely systems could be devised to enable patients to rate NHS performance in a ‘real-time’ basis.54 Movement in this direction has been taken in the Friends and Family Test which measures whether patients would be ‘net promoters’ of the hospital in which they were treated.55 Promoters give a positive and unequivocal recommendation to others about the hospital; those ‘extremely likely’ to do so are promoters. Those who equivocate by being merely ‘likely,’ or who are ‘unlikely’ to do so, are not promoters. The idea is to subtract from all the promoters the total of those only ‘likely’ or ‘unlikely’ to do so to obtain a net promoter score. This creates a reference point by which comparisons can be made and may have a salutary impact on culture from the bottom-up. No doubt the present arrangement is crude and should be improved upon, but the purpose is laudable—to give patients a clearer voice in measuring hospital performance.

Second, as to clinicians, we have discussed the heuristics and biases that can distort Hippocratic instincts. The history of failures suggests that clinicians are not capable of addressing this risk alone. Francis recommends a statutory duty of candour and a clearer set of ‘fundamental standards’ which everyone will agree to56; perhaps that prescribed medicines should be administered, patients should be given food and water, kept clean and taken to the lavatory. Contracts between commissioners and providers must include terms which require providers to disclose to patients an ‘unintended or unexpected incident’ and any subsequent steps taken to manage the risk.57 This statutory duty between commissioners and providers is of indirect benefit to patients and there is no penalty for breach. Will it work? Duties of candour confront a powerful contrary force that seeks to protect clinicians from blame it regards as unfair. For example, the Bristol Report criticised medical negligence litigation because: ‘By institutionalising blame it breeds defensiveness. The instinct is to cover up and deny.’58 To overcome this instinct, Francis recommends criminal sanctions against those who breach these duties. Despite the threat, clinicians may welcome a statutory, non-negotiable endorsement of their most basic duties to patients as a way of assisting their discussions with managers.

Third, managerial culture deserves special attention. The circumstances of Mid Staffordshire create the impression of an organisation more concerned with protecting itself than patients. Francis recommends that managers are subject to an absolute duty of openness, transparency and candour, supported by criminal sanctions for breach and included in the Code of Conduct for NHS Managers. The new duty would insist failings are never concealed and that half-truths and omissions about performance never misrepresent the whole story. Loyalty to the organisation should never displace the primary duty to patients and the public. Should concurrent duties to shareholders make a difference? Private hospitals providing NHS services should be no different. Commitments to NHS patients should be the same, regardless of who provides the service. The ‘Nolan’ principles of for example, ‘selflessness, openness, honesty and accountability’ should apply to them as they do elsewhere in the NHS. These obligations should be fundamental terms in every contract agreed with NHS commissioners and made enforceable by patients.59

Fourth, Mid Staffordshire focuses on one hospital in particular, but government must confront its impact on NHS culture in general. Francis criticises the Department of Health for being ‘too remote from the reality of the service they oversee’ and for issuing directives interpreted lower down as ‘bullying;’60 There appears to have been no significant change since the Bristol Report in 2001. Compassion in the NHS should include the government's regard for the position of NHS managers. For example, the Department of Health may have to be more receptive to reasonable argument, for example, that achieving a waiting time target should be postponed. Francis also criticises the constant structural turmoil in the NHS. As long ago as 2003, the NHS was described as an ‘organisational shantytown in which structures and systems are cobbled together or thrown up hastily in the knowledge that they will be torn down again in due course.’61 In 2013 Francis said: ‘The reorganisation of the structure of SHAs,… primary care trusts and providers in 2005–2006 appears to have been conducted without any assessment of the risks to patient safety or the quality of service posed by the process of change.’62 The process is relentless. Each reorganisation disrupts corporate memory, dilutes experience, undermines confidence and increases the likelihood of failure. The disregard for the impact of structural reorganisation in the NHS is striking. In future, ‘impact and risk assessments should be made public and debated publicly, before a proposal for major structural change to the healthcare system is accepted.’63 This is an echo of the less confrontational style of ‘consensus management,’ so criticised for impeding decision-making in the 1980s that demands sustained scrutiny in future.64

We have been grappling with the problem of institutional disengagement from patients for years. As Professor Sir Ian Kennedy warned in 2001: ‘The history of the NHS is littered with the reports of Inquiries and Commissions: most have soon been consigned to gather dust on shelves… It will only be a matter of time therefore, before the same, or a similar set of problems arises again...’65 Today's challenge is exacerbated by the reductions in real-term NHS funding and the destabilising new structures introduced by the Health and Social Care Act 2012. Some argue that the ‘de-nationalisation’ of the NHS further dilutes public values.66 Should we be confident of better progress this time? As Francis says: for all the ‘fine words’ about candour, and willingness to remedy wrongs, ‘there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism.’67 Financial austerity, institutional instability and political anxiety do not provide firm foundations for optimism.6,8