Mid Staffs NHS Trust: Governance and Leadership

Introduction

The Mid Staffordshire NHS Trust recorded one of the biggest health scandals in the world. The Trust, which managed the Stafford Hospital, was accused of mismanaging funds and inadequate management of the hospital. The public was irritated by the appalling conditions of the hospital facilities seeing that it was a non-profit organisation. Many reported that treatment in the centres managed by the Trust was the main cause of the mistreatment and death of patients (Campbell, 2013). Several factors of management led to the scandal. For example, the Trust tasked a board to make all the decisions associated with the hospital. Members of the board invested in the hospital and appeared to have invested in the hospital for a different reason other than ensuring quality healthcare (Campbell, 2013). In the end, the whole scandal was uncovered, and the public outcry was explicit. Investigations were opened on the hospital and the Trust in general. One such inquiry was the Francis inquiry. The first report of this inquiry was released in 2009 and it proved that the hospital provided low-quality healthcare. The second report proved that trust misappropriated resources (Campbell, 2013). This report gives a detailed account of the factors of management that were ignored by the board of the Trust. Additionally, the paper analyses the reasons why the problems mentioned occurred and provides suggestions on what can be done to move forward.

Background of the Governance Crises of the Mid Staffordshire NHS Trust

There were numerous cases of incompetence in Stafford Hospital, which was managed by the Mid Staffordshire NHS Trust. The incompetency registered had been blamed on bad governance. For example, as Holmes (2013) reveals, the years between 2005 and 2008 were not excellent for trust. For example, Holmes (2013) quotes the Francis report that showed there was inadequate staffing in the hospital. It was up to the Trust to hire more people, but it did not. Roberts (2013) observes that a majority of the stakeholders blamed the managers at the time; the Board. It was ironic that the board that was under scrutiny had replaced the previous managers of the Trust under the claim that they were not doing a good job. It suffices to mention that, even though the board was accused of bad governance, it still registered some achievements. For example, it helped the Trust upgrade to the Foundation Trust status from the Mid Staffordshire General Hospital NHS Trust status. It has been argued that such achievements shadowed the poor conditions experienced in the hospital.

At the time when the Trust was being upgraded to an FT status, the Strategic Health Authority had to ensure that it was capable of handling the responsibilities that came along with the title. Woodmansey (2011) claims that the Trust was approved on merit to have the right type of governance to help it as an FT regulated by the Healthcare Commission. The results of the investigations were surprising to many, as there were high mortality rates in the hospital. Also, many patients had complained of low-quality care. The pressure from the public led to thorough investigations that showed the appalling status of the Trust. All of this was blamed on the Board, which was in charge of governance (Campbell 2013).

The Board decided to suspend the Chief Executive after poor management was identified as the core factor of the deteriorating mortality rate in the hospital (Spencer-Lane, 2014). The Healthcare Commission (2009) argued that the public was angered by the suspension, as the CEO still got her full pay while on suspension. The Trust had to ensure that no more public outrage erupted; therefore, the Chairman of the Board resigned.

It is crucial to point out that some officials were involved in the scandal, but they were promoted. For example, David Nicholson, who was a key member of the Trust, was promoted. Alongside him was Cynthia Bower, who had run as CEO before and been demoted due to poor management. The public and health care organisations were not pleased with the promotions. Consequently, the Secretary of State of Health ordered further investigations into the Trust and the hospital to be done. The investigations came up with several suggestions on what needed to be done to solve the problems of management in both the Trust and the hospital they were operating. One of the direst suggestions was the de-authorisation of the Trust. The proposal meant that the Trust would be stripped of their ability to run the hospital (Brown & McMurray 2014). In turn, the hospital would hire better managers to run it or partner with a renowned hospital and leave the management of the new hospital to run it. The hospital was also required to give reports to the Healthcare Community. Additionally, some health care agents were assigned the task of monitoring all the activities in the hospital. This meant constant reviewing of patient information, doctor skills and experience, and the drugs that were stored in the hospital.

The Trust had already made a mess of its public image; thus, there was little they could do to avoid angering the public (Spencer-Lane 2014). It took the intervention of the Prime Minister and the Health Secretary to appease the masses, whereby they offered a public apology. They also swore to ensure that full investigations would be done to uncover the main problems in the Trust. To add to this, both agreed that the families of the people who had suffered or lost their lives in the hospital would be compensated.

Corporate Governance

The management of any organisation, whether non-profit or for-profit, can be a tricky affair. There are a lot of things that one has to think about when managing any form of organisation. This section of the report will discuss the main principles that should be used in any governance and leadership position. Also, a detailed discussion of theories of leadership will be presented. Both the principles and the theories will be tied to the Stafford Hospital case.

Principles of Management

Weberg (2012) argues that ten main principles should be used in a management position. The first principle is the board’s responsibility for governance. The principle denotes that it is the board that should be held accountable for any successes and failures of management (Napier, 2013). In the case of the Stafford Hospital and the NHS Trust Board, the Board was held responsible, and some members had to be suspended, while others resigned. The second principle is transparency. According to Phipps and Burbach (2010), transparency is the same as clarity. The organisation should be an open book, without too many agendas and secrets. The NHS Trust Board tried to create secrets, but the public was soon made aware of the secrets. For example, they attempted to promote some executives who had been involved in scandals. However, the public became aware, and public action forced more investigations into the matter. Moreover, several other investigations had been done, but none had suggested that the hospital was being mismanaged. This highlighted some fishy deals that had been made to protect the Trust.

Also, Pearse (2011) argues that commitment is a crucial principle in management. Any manager or body that is given the task of managing an organisation has to be committed to the cause. Drawing from the case of the NHS Trust, the Board had to be committed to helping the sick. It can be argued that they did not have this commitment; that is why they did not do anything of importance to ensure that the mortality rates were reduced. Their arrogance was also highlighted when they decided to suspend the CEO, while still giving her full salary. The board also has to be objective. In the case of the NHS Trust, the Board should have solved the problem more amicably. However, they dragged the Trust through the mud by making all public relations blunders in the book. They did not see the bigger picture and assumed that the press and the public would not probe further.

Goldkind (2013) asserts that an independent board form of leadership is an important principle in management. An independent board, in this sense, refers to a board that has not invested in the organisation (Brink, 2011). Such boards do not allow direct stakeholders of the organisation to participate in the board decisions. The advantage of having such a board is that all the decisions that are made are not influenced by affiliations to the direct stakeholders. Ethics is another crucial principle of management, according to Trebble et al. (2014). The ethics used in business can indeed differ from personal ethics. For example, on a particular ethical stand, one can argue that the Trust was wrong in ignoring the poor conditions the hospital was in as the Trust was too busy trying to make as much money as possible. However, from a business point of view, one can argue that the Trust was doing the best it could with the little money it had. To solve such ethical dilemmas, organisations must come up with ethical rules and guidelines that shape the activities conducted by the organisation.

Another principle of management outlined by Broscio (2014) is communication. Proper communication is essential for any organisation to succeed (Vakkur & Herrera, 2013). In the case of the NHS Trust, the communication should have been between the hospital and the Trust. Indeed, it can be assumed that the two entities did communicate. However, after investigations were run, it was realised that communication breakdown was one of the leading factors of the management disaster registered. The communication model employed was a top-down approach. It meant that communication would only flow from the top shareholders’ ad trickle down to the last person in the organisational ranks. The main disadvantage of this type of communication is that there is no way a junior person in the organisation will be heard. If the junior staff at the hospital were allowed to talk and make suggestions, they would have identified the weak links and the whole scandal might have been avoided.

Theories of Leadership

As mentioned, two things have to be considered when dealing with management; the principles of management and the theories of management. This section focuses on some of the principles of management that have been proposed over the years.

Different scholars have come up with numerous theories that can be used to analyse management practices. One of the oldest leadership theories is the Great Man theory (Iverson 2013). The theory states that leadership is intrinsic; one has to be born with because leadership cannot be learned (Delmatoff & Lazarus 2014). Therefore, for any organisation to succeed, the stakeholders have to ensure that they pick the best candidate for the CEO position. Similarly, any other person who takes any form of the leadership role must have been born with leadership skills. In analysing the case at hand, a person using this school of thought would argue that the CEO and other Board members were not born with leadership skills. That is why they had inadequate skills in running the hospital and the Trust.

Pacaia (2012) also explains that several behavioural theories of leadership have been defined over the years. The Trait theory states that leaders should be judged on their abilities and behaviours. In other words, leaders should not be judged on whether they were born with leadership skills or not. In so saying, these theories reject the concept proposed by the Great Man theory. The behavioural theories introduced the statement “leaders are made, not born” to management and leadership studies. Ironically, the trust has a competency framework that is used in the hiring process. However, the personnel still fell short and delivered bad services to the patients because they were very few. Also, the Trust directors were not as competent, thus, making administration mistakes. Drawing on and analysing the NHS Trust case using the behavioural theories, one might argue that the Trust leaders involved in the case lacked the right behaviour and personalities associated with leaders.

Another leadership theory that has been highlighted by numerous scholars is the contingency leadership theory. Rashid and Islam (2014) and Carroll and Buchholtz (2012) explain that Fiedler’s contingency leadership theory states that each leader will have their unique leadership style based on the situation at hand. The leadership style can also change based on the situation experienced. In the case of the Foundation Trust, it was using the contingency leadership theory by acting according to the situation at hand. Therefore, giving the CEO a full salary while she was suspended and promoting other executives was the best way to deal with the situation.

Last, but not least on the list of leadership theories are the transactional theories. Meintjes and Grobler (2014) explain that these theories argue that good leaders are people who interact and make decisions together with their employees. For example, transformational theories that were expanded by Bernard Bass encourage the leaders to gain the trust and respect of the employees in an attempt to foster good working relationships (Brink, 2011). As such, the leaders interchange ideas with the employees on how they can manage the company better. According to Sarra (2011), it is the only theory that offers mutual benefits for both the leader and the followers. In this sense, the leader gets to know what the followers need and want, while the followers get to not only air their views but also give them exposure in terms of management, leadership and administration. The NHS case can also be analysed using this theory. One way of investigating the case using the transactional theories is through examining the relationship between the hospital and the Board. If the Board and the hospital staff were working together, then the hospital staff cannot complain that the board initiated poor management that led to the deplorable environment in the hospital. However, it was relatively possible that the board did not interact with the staff in the hospital, which resulted in the accumulation of management problems. The Francis report proved that the Department of Health, the local Strategic Health Authority, the Trust, the Independent Regulator, and all other bodies that were involved with the hospital and the trust, in general, did not have a strong communication process in place.

Recommendations for the Development of Governance and Leadership

A lot has been proposed by the government, Strategic Health Authority and the public on how the hospital and the Trust can regain their once ‘near-perfect’ public image. Some believe that the whole board should be sent packing, while some suggest that only some members of the board should be sent home. This section provides suggestions and recommendations on some of the things that can be done to improve governance and leadership in the Stafford Hospital and the Mid Staffordshire NHS Trust.

To make recommendations, it is crucial to first discuss the exact theory that was used in the case at hand. The transactional theories would best describe the situation experienced at the Stafford Hospital because they allow the leader and the follower to interact on a deeper level, thereby understanding each other’s needs. As mentioned, communication in the whole organisation was from the top to the bottom. In this scenario, the top is the board, while the ‘bottom is the staff in the hospital. The employees were managed by the Board; thus, the hospital staff had to do everything that the Board said. It is this relationship that the Board was blamed for everything that went wrong in the hospital.

It suffices to mention that the hospital staffs were mentioned adversely during the investigations, especially with regards to their qualification and their ratio to patients (Francis Report, 2013). One can argue that the investigators went only after the Board of the Trust and let go of the employees of the hospital. After all, it was the doctors who were giving treatment to the patients and not the Board. However, a more likely scenario, as Francis Report (2013) observes, is that the hospital staff had their hands tied. They were not getting any form of active support from the Trust and the Board.

In light of the problems that were experienced, it is only fair to state that adopting an independent Board is the first recommendation. Many of the Board members were prominent stakeholders in the health industry (Lync, 2010). Thus, the decisions that were made were biased and only made to benefit the stakeholders. An independent board would not have such biases. It would make decisions that best suit the organisation. On the issue of necessary knowledge, the board will have to be informed on all the past and present cases that involved the hospital. It should be provided with all necessary documents to ensure that the board members fully understand the state of the hospital, the things it can do, and the things it cannot do. For example, the board decided to give the CEO a full salary when she was on suspension. The main reason behind this is that the suspension was not used as a way of helping with the investigations or punishing the people responsible but as a way of showing the public that something was being done. The CEO was suspended so that people would stop complaining that the Trust was not doing anything to punish the people responsible. Also, the CEO got her full salary package because the Board realised that they were all in the wrong; thus punishing one person would be unfair. Every reason that was used to settle on the suspension of the CEO was for the benefit of the people on the Board.

In most cases, an independent board would not have been in the same predicament in the first place. If the Board members of an independent board were caught with the same problem, all the decisions that would have been made henceforth would have been to protect the company and not a few people.

In addition to the independent board, the Trust can also change its communication strategy. As mentioned, communication is essential in any form of organisation. Bach and Kessler (2012) argue that the top-down approach is the worst communication model in an organisation because it does not leave room for emergency communication.

The hospital should adopt a flexible communication strategy; one that allows people to act on situations faster and more efficiently. Using the same example of the oxygen tanks, in a flexible communication strategy, the nurse would tell the nursing manager in the hospital about the problem. The nurse manager would then go directly to the people responsible and raise the issue with them. They would then come up with a solution. At the end of the month, a report would be written, and the situation that was solved would be included in the report. The report would then be presented to the board members for deliberation, and any questions that may arise would be directed to the nursing manager. This type of communication is not only faster, but it ensures that things are done well. It also encourages accountability among the employees.

Conclusion

In conclusion, the Mid Staffordshire NHS Trust committed every crime of management in the book. The Board had a personal interest in the hospital and lacked commitment, accountability, transparency, communications, ethics, and objectivity to ensure that the hospital was managed well. As a result, patients received low-quality health care, and some died. Moreover, the Board continued to make more mistakes, which led to further investigations into the whole organisation. The transactional theories of leadership help in understanding the problems that the Trust faced. According to the theories, the interaction and relationship between the leader and the followers are crucial. It is through this relationship that proper communication strategies flourish and make the management more effective and efficient. That is what the Mid Staffordshire NHS Trust should adopt to avoid such crises in the future.

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