The two most shocking revelations to emerge from the investigation into Liverpool community health NHS trust are that every part of the system failed, and it happened even as the trust was considering what it should learn from the Mid Staffordshire scandal.
The independent review by Dr Bill Kirkup into events at the trust between 2010 and 2014 shows the root cause of the trust’s problems was an inexperienced and bullying leadership obsessed with achieving foundation trust status, irrespective of the effect on patients. This toxic culture seeped into every part of the organisation, breaking the morale of frontline staff and inflicting serious clinical harm.
Those brave enough to raise concerns risked bullying, harassment and suspension.
It was a dysfunctional organisation from the moment it was created in 2010 with an inexperienced and inadequate management team. Two clinical commissioning groups and NHS England pushed it to achieve significant savings, which had a serious cumulative impact, but the trust made matters far worse with self-imposed cost cuts in pursuit of its managers’ dream of foundation status.
Kirkup points out that achieving annual cost improvements of 4% is the outer limit of what can reasonably be achieved; Liverpool tried to deliver a 15% cut in one year, apparently oblivious to the risks.
Governance was a mess. At times the finance director was responsible for clinical quality and the nurse director was the chief operating officer, so no one was championing patient care.
Staff tried to keep services going but morale collapsed and sickness absence rose. Pressure sores, falls and extractions of the wrong teeth were among the consequences. Reporting of serious incidents was discouraged. Middle managers under pressure to do the impossible lashed out at junior staff. There was a climate of fear, intolerance, disbelief and insecurity.
HR records reveal appalling treatment of staff, including arbitrary disciplinary processes and prolonged suspensions without reason. It was not uncommon to see staff crying in the car park.
Among the most egregious examples of abuse were the so-called scoping meetings, supposedly convened to investigate safety incidents. In practice they were “an interrogation and a frightening experience”. Staff reported feeling physically sick beforehand and approached them with trepidation. Across the organisation shouting and finger-pointing became the norm.
In what appears to have been an attempt at empire building, the trust took on responsibility for health services at Liverpool prison – which was recently condemned by inspectors as having the worst conditions they had ever seen. The trust’s failures in the prison harmed more patients.
Liverpool’s board discussed severe cuts to its workforce – notably nursing – at the same meeting it considered the findings of the Francis inquiry into Mid Staffordshire, the lessons from it apparently eluding them.
The strategic health authority failed to spot the problems. Subsequently the NHS Trust Development Authority identified concerns, then inexplicably reversed its assessment. The Care Quality Commission also failed to identify the problems until it was alerted by local Labour MP Rosie Cooper after staff spoke to her.
The trust has been broken up, but the lessons from its collapse need to live on. It shows again how, controlled by an oppressive culture pursuing unrealistic financial goals, an organisation can quickly mutate into one that harms the very people it is there to serve.
Senior clinicians need to keep a clear focus on their professional responsibilities and not be swayed by board denial or groupthink.
Non-executives need to get out from behind their board papers and keep in close touch with staff and patients. They are there to offer constructive challenge to the trust leadership, not to assist them in pursuing impossible goals.
But above all, the Liverpool scandal demonstrates yet again that an open culture which listens to staff needs to be at the core of every NHS institution. Instead, dissent was crushed and a culture of denial allowed patient harm to proliferate. A cursory glance at the annual staff survey would have been enough to reveal that something was badly wrong.
If staff do not feel able to speak up, something is rotten at an organisation’s heart.