Culture, maternity failures and the Ockenden review: a case study
Those with an interest in health scrutiny will have been keeping a watchful eye on the developing independent review of maternity services provided at Shropshire and Telford Hospitals NHS Trust. Donna Ockenden was commissioned to undertake this review two years ago following a number of serious clinical incidents; since then the scope of the work has expanded. As things stand, the review is looking at a range of around 600 cases from 1979 to 2018. The review team is looking at the quality of investigations into the cohort of incidents identified through Ockenden’s early work, and to establish how these investigations led to change. This may involve a second-stage review of some of the primary cases.
This is a review of significant scope and scale. It bears significant similarities to other systemic failures in NHS trusts – most obviously the Stafford Hospital scandal ten years ago. Both cut to the culture of the NHS, and the attitude and mindset of both clinicians and Trust management.
This has been thrown into sharp relief in the past few days. Donna Ockenden has had cause to complain to hospital management and to NHS England about the “poor judgement” of some staff who endorsed a letter that questioned the review and its work.
The response from the hospital is instructive and demonstrates the depth of the issue. The Trust’s interim chief executive said at the end of a statement, “Please be assured that the intention was never to cause distress” – instructive because it provides tacit support to the review’s focus and scope being questioned. It justifies pushback against investigation and is defensive in an environment where defensiveness is untenable as a corporate response to a crisis.
What does this have to do with health scrutiny more generally? It cuts to the heart of the challenge with which we are faced when health scrutiny challenges NHS bodies. The NHS is seen as something to be defended, championed, supported – rightly. It provides a vital service, is massively valued and held in high esteem. But it is possible for this high esteem to be co-opted to push back against criticism and challenge.
Sometimes, health scrutiny will find itself working with the grain of the local community – when a critical local service is proposed to be decommissioned or closed, for example. But sometimes scrutiny will find itself in a more challenging position, highlighting and challenging poor practices. What can we do when this happens?
Firstly, we need to return to scrutiny’s core tasks in respect of health services. Scrutiny does and should have a general power – held in common with a range of others in the local community – to hold to account the design and delivery of local health services. This need was recognised in the Francis Inquiry and is a thread running through more recent Government guidance.
These rights and powers are occasionally not recognised by health partners. Scrutiny is not shut out – but NHS partners can work in a way that inadvertently or otherwise makes it difficult for scrutiny to add value intelligently and effectively.
Particularly in the coming years, this is likely to be a pressing issue. With the transformation of local health systems coming as part of the Integrated Care Systems (ICS) agenda will come a need to ensure that clinical outcomes remain a key focus while financial and structural changes make accountability within the NHS more fluid and uncertain, for a time.
How these changes will affect the prevailing NHS culture remains to be seen. They may make those operating within new systems more open, more candid, more questioning of existing practice. Or they may have the opposite effect. Scrutiny has a role in pushing attitudes and behaviours toward the former outcome. As a critical system partner, scrutiny has a right and duty to be part of these changes – and to engage meaningfully with NHS bodies on culture, not just on the mechanics of “substantial variation”.
Now is the time to start discussions about how scrutiny’s input into the ICS agenda ought to be framed – and in our view culture should form the core and foundation of this engagement. Accountability, responsiveness, inclusiveness – these are all features of a well-governed public space, and councillors are best placed to support the fostering of the environment where these features can flourish.
We are working with health partners nationally at the moment to develop further guidance – to primary care networks, to other partners across the system and – hopefully – to scrutiny itself, on how to manage and handle this change in a proportionate way that ensures that these critical factors are not lost.
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