First, I read in The i (a daily digest from The Independent):
Hospital inspections cannot be trusted, the head of the NHS watchdog admits. David Prior, new chairman of the Care Quality Commission (CQC), made the stark admission after top officials at the health watchdog were revealed to have supressed a report highlighting failings at the Univeristy Hospital of Morecambe Bay NHS Trust. More than 30 families are taking legal action against the hospital.
The Trust is being investigated by police over the deaths of eight mothers and babies.
Mr. Prior told his board: "We can have no confidence, I think, not just at Morecambe Bay but across many more hospitals, that we have done a proper job." He also admitted to the BBC that the CQC was "not set up then, and we're not fully set up now, to investigate hospitals."
[Health Secretary Jeremy] Hunt told the Commons . . . "A culture in the NHS had been allowed to develop where defensiveness and secrecy were put ahead of patient safety and care."
The instant case includes the destruction of evidence, and The Daily Telegraph notes:
The NHS watchdog was last night accused of "broader and ongoing coverup" after refusing to name officials who ordered the destruction of evidence of its failure to prevent a maternity deaths scandal.
Jeremy Hunt . . . demanded that those responsible for the apparent cover-up ultimately be publicly identified, despite defending the CQC's decision not to name the individuals immediately.
The CQC claimed it could not disclose the identities of those who ordered the destruction of [the] report . . . due to data protection laws.
MPs derided the CQC excuse, saying it was in the public interest that individuals who destroyed evidenc be named.
Well, here we go again. The body politic wants the blood of individuals, responding with an "off with their heads" approach. An editorial in the Telegraph jumps on this bandwagon, saying "Until individuals are held accountable for these appalling misdeeds, the culture will never change, however many structural reforms are undertaken."
While it is dangerous to judge from afar, I think this is the wrong focus, for it is clear that there are rampant systemic problems in the organization. Look at this:
Dr. Heather Wood, who led the investigation which uncovered the Mid Staffordshire Hospital Trust scandal, in which up to 1,200 people died, accused the CQC of operating under a "culture of fear, which mimicked the very worst aspects of the NHS."
Such a culture does not arise over night. While there might be short-term culpability among staff members, the people to blame are the senior leaders who have allowed their teams to develop practices and patterns of behavior that undermine the purposes and mission of the organization.
I recently wrote about a different kind of organizational failure, the highly publicized mistakes made by a division of the US Internal Revenue Service. Referring back to an article I wrote in the Harvard Business Review, entitled "The Nut Island Effect," I explained one kind of dynamic that results in good teams going wrong. Whether the problems at the CQC parallel those of Nut Island or whether they reflect some other organizational failure, it is the senior leadership who should look in the mirror rather than asserting the exclusive guilt of others under their supervision. Meanwhile, back at the NHS trusts themselves, questions still remain unanswered from their boards.