Nationwide study brings NHS 'dark spots' to light

The quality of care in the English NHS is too often compromised by a lack of clearly defined goals, too much regulation, and highly variable staff support, according to the largest ever study of NHS culture and behaviours.

Details of the study were published online in BMJ Quality & Safety, and the research team was led by Professor Mike West of the Centre for Performance-led HR.

While West and his team found many examples of exemplary and innovative care, they also found that issues like those revealed earlier this year in the Robert Francis Inquiry into what went wrong at Mid-Staffordshire NHS Foundation Trust are likely to be found elsewhere, even if not to the same extent.

"Though Mid-Staffordshire may have been one particularly 'dark spot' in the NHS, organisations throughout the NHS are likely to have at least some shadows," say the authors, adding that their analysis showed that "there was little confidence that care could be relied on to be good at all times in all parts of organisations." 

Their findings stem from a two-year research programme, commissioned by the Department of Health, into prevailing culture and behaviours in the NHS. The research covered the period from 2010 - after the initial inquiry into events at Mid-Staffordshire - to 2012 when Health and Social Care Act brought into law the latest reforms of the NHS in England.

A variety of sources were used to inform the work: 300 interviews with senior-level executives, managers, and frontline staff, patient and carer surveys, board minutes and published datasets on performance in all types of NHS trust, and cultural (ethnographic) case studies of hospital wards, primary care practices and emergency care departments. 

Key issues to emerge from the research were:

  • Unclear/disjointed goals leading to 'priority thickets', which eat up resources but provide little in the way of clarity or coherent strategy
  • Excessive box ticking to comply with external requirements rather than improve services
  • Multiple regulatory bodies and other external agencies serving different but overlapping functions, leading to ambiguity, fragmentation, and competing pressures
  • Poor intelligence on which to base decisions/improvements
  • Highly variable staff support and a lack of respect and appreciation
  • 'Comfort-seeking’ behaviours', which focus on making a good external impression and view staff who raise concerns as trouble-makers and whiners
  • A lack of integration, leading to time-wasting, frustrating barriers, and gaps in care
  • Indiscriminate or inappropriate use of quality improvement management techniques and a belief in 'magical thinking' - that the initiative will solve many problems quickly and easily
  • Variable quality management 

Ways forward

The study includes recommendations for improving the service, and these have already helped to inform recently published government reports (see box on the right) on patient safety in England. 

The authors emphasise the need for coherence of national direction – essential for ensuring that responsibility and accountability are not dispersed and for avoiding confusing messages and signals. The NHS needs "clear and explicit goals that are coherent from ward to Whitehall," they say, and it is also vital that organisations should have good intelligence on their performance if they are to improve: "This means actively seeking uncomfortable and challenging information from patients and staff".

Organisations across the NHS need to constantly review, strengthen, and improve all their systems, and focus on developing cultures that are person- rather than task-centred.

"It is especially important that organisations do more to ensure the engagement and health and wellbeing of their staff because our research shows strong links between staff experience and patient mortality rates," says Professor West. "Looking after patients requires looking after staff.

"This major national research programme has helped us to understand how to create the conditions for staff to deliver high-quality, safe and compassionate care across the NHS.

"Our study shows many such examples of care that are beacons for all NHS organisations. The challenge ahead is supporting leaders to get the conditions in place so that staff can do what they most want to do – deliver high-quality, compassionate care for the people of their communities."