Mid Staffordshire NHS Foundation Trust, hereafter, Mid Staff is a 344 Bed Trust commissioned as Stafford Hospital in 1984. In 1992, management of Cannock Chase Hospital and Stafford Hospital developed a working policy to provide acute and emergency care services to patients in the current Mid Staff system. Authorised as a foundation trust in 2008, Mid Staff offered well-organised services to the ailing patients with specialised care for the less fortunate members of the society. It offered a reprieve to the poor with efficient service delivery and wonderful health care services. However, towards the end of 2009, Mid Staff underwent a serious transformation following a series of public complaints. As later reported by Robert Francis led commission of inquiry into the management and health care service provision levels, the service at Mid Staff presented health hazards to the poor patients. Health care service delivery changed from service provision and patient care to gross neglect and suffrage to patients. As reported, between 2005 and 2009, more than one thousand patients died in the Mid Staff facility. Majority of the fatalities took place due to gross neglect and irresponsible act from the doctors, nurses, and other medical practitioners trusted with the role of ensuring proper care and medication for the patients.
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In criticism and vilifying of the management structure at the Mid Staff, Sir Ian Kennedy, representing the health care regulatory authority, Health Commission, described the scandal experienced at the Mid Staff as not only horrifying but also the worst hospital health care scandal of the recent times. After several complaints from the members of the public, the commission of inquiry initiated a public consultation and stakeholder engagement forums in which the affected patients narrated their ordeals (Regulators Consider Dissolving NHS Trust 2013). The outcomes of the inquiry led to the development of 290-recommendations report under which the Mid Staff management unit needed to implement before their re-entry into the health care service provision (Andrew 2013). This paper seeks to explore the leadership and governance deficiencies in the Mid Staff that contributed to the scandal. Similarly, the paper seeks to explore the governance and leadership principles and theories that the Mid Staff management unit overlooked in their management roles (Hawkes 2013).
Governance and leadership
Governance and leadership units in health care service institutions are the accounting and decision making organs. Their roles and strategies towards improved service care and efficient patient care represent the ability of the individual institution to develop adequate patient care systems (Grady 2010, p. 124). However, Stahl (2004, p. 18) denotes that many leaders, managers, and decision-makers in the health care service provision institution divert their energies towards increased financial performance and fundraising at the expense of the health care services. Mid Staff management unit represents the leading casualty from this school of thought with an increased emphasis on fundraising and financial capabilities. The effects of such poor and irresponsible decision are increased death, reduced customer numbers, and sometimes close down of health care facility. However, with the growing public oversight and increased government interests in the private health care service providers, this trend continues to reduce (Bekkers 2011, p. 108). As Wager and Lee (2009) assert, the amount of information available to the public and the relatively liberalised systems of oversight and reporting continue to check the management structures put in place by the private health care service providers. It is through such structures of public outcry and government oversight that the Mid Staff management units faced a public grilling over their irresponsible decisions that led to the death of more than one thousand persons between 2005 and 2009 (Barr and Dowding 2012, p. 74).
Approaches to leadership and governance
Strengthening governance and accountability
On a personal point of view, several scholars view accountability as the ability of an individual to answer to the actions he/she undertakes. However, in the health care service delivery accountability and good governance revolves around all the institutions in the health sector, developing meaningful structures for executing the primary mandate of efficient health care service provision. As institutions mandated to protect and hence human life, accountability and good governance in the health care service providers must develop initiatives for creating an ample environment for ensuring fair, inclusive, and trustworthy service provision devoid of ill motives such as commercialisation health care institutions (Regulators Consider Dissolving NHS Trust 2013). To develop strategies for ensuring accountability management unit in the health care service provision, the institution must develop fidelity characters to the main mandate with utmost openness, transparency, and responsiveness to the needs and aspirations of the patients. In the Robert Francis led commission of inquiry, evidence showed that the management unit at Mid Staff veered off the main objective in health care and focused on commercial activities such as fundraising and financial stability. The management unit failed to appreciate the importance of human health at insolvent health care organisations but rather focused on ill health and deaths at a finically stable health care service provider (Vaughan and Arsneault 2014, p. 36).
Strengthening health care systems, leadership and management
As evident in the Mid Staff scandal, there exists a correlation between management structures and the effectiveness and efficiency in health care service delivery. Poor management and leadership structures necessitate irresponsible and fatal decisions. Inadequate health care management systems present a prerequisite for productivity failure (Arnetz and Blomkvist, 2007, p. 246). Strengthening health care systems, leadership, and management cultures, therefore, plays a vital role in developing, and effective service delivery program. Health care management systems set out clear objectivities and roles of the various stakeholders engaged in the sector, such as patients, government officials, and other civil advocacy organisations. With a structured system of management, public reporting and complaints systems record inconsistencies within the health care service providers. These complaints, together with government supervision, and audits, compel management units to develop effective health care service system. Conspicuously absent in the Mid Staff health care management system was a complaints registry through which patients could table their dissatisfaction with the service delivery unit (Blais and Hayes 2011, p. 39).
Procuring and managing technical assistance for good health
Even though some several health care service providers recruit and develop highly qualified personnel to ensure proper service provision, and oversight of the role of third party opinions on the management of technical expertise offers a vital starting point for poor service provision (Mcalearney 2005, p. 503). Despite Mid Staff having qualified personnel in the service provision, their rooting into the culture of neglect and irresponsible acts complicated their ability to rectify the situation. The report developed by the commission indicates that third-party analysis from an independent consultant helps health institutions develop the gaps and management mishaps before fatalities. Similarly, procuring technical assistance from external health practitioner help firms strengthen their policies, plans, and monitoring systems. Likewise, independent external consultants in the health care service provision help health organisations develop responsiveness and accountability strategies necessary for efficient service delivery (Gallouj 2010, p. 63). Mid Staff management structures lacked adequate responsiveness and urgency to human health conditions hence required an urgent external force to alarm the management on a looming crisis.
Transparency and corruption prevention approach
In the world today, corruption remains an international ill that needs a thorough and adequate address. In all the sectors of the economy, corruption exhibits in the form of abuse of entrusted authority to gain illicit mileages (Hess and Orthmann 2014, p. 75). In the health care service provision, corruption ranges from the provision and supply of counterfeit drugs to illegal and improper charges on patients. Similarly, in the effective and lame accountability for resources meant for service delivery presents an ample avenue for misuse of public resource for illegal gains. In the Mid Staff scandal, reports indicate that conversion of the institution into a trust in 2008 set a basis for the focus on fundraising and commercialisation of service delivery. The charges for service, albeit poor, remained high despite cries from the patients. The management units of the institutions focused on amassing more financial resource for the trust at the expense of developing health care solutions to the patients. Mid Staff lost track of its original mandate due to the failure of the management unit to uphold their vision and mission (Lewis 2006, p. 47).
Although many practitioners prefer the broad und understanding of corruptions and related ills, it is vital to note that the Mid Staff management unit failed to appreciate the role of public oversight in ensuring adequate service provision. Similarly, patients lacked necessary information on the cost of services within the systems thus failed to assess the correctness of bills. The inability of the patients to ascertain and confirm the charges accrued provided a basis for extortion like system within the Mid Staff with reduced accountability. To stem out corruption in the health sector, there exists a need to develop good governance principles based on information, transparency, accountability, integrity, and public oversight (Ramani 2008, p. 40). Such principles remained absent in the Mid Staff service charter. Corruption is a wide issue in the health care service providers ranging from engaging several players in the market. Efforts towards combating this vice need a combination of legal, institutional, and personal performance measures. Personal performance measures come in at the organisational level and help create a culture of ethically responsible employees and stakeholders (Ritzer 2004, p. 92).
Strengthening voice, accountability, and civil society
In all the sectors of the economy, accountability and responsibility play a vital le in ensuring efficiency in production and service delivery. At Mid Staff, accountability seemed absent, and the role of public and civil society voice remained dormant. Until the death of more than one thousand individuals, the management systems at the institutions disregarded the public outcry with uttermost contempt and gross irresponsibility (Vian 2010, p. 109). In the findings of the public inquiry, it was evident that the structures for public and patient involvement in decision-making as well as the inclusion of local government recommendations on service delivery were absent. As recommended in the commission, Mid Staff must consider the inclusion of patients and other stakeholders in decision making through groups representatives and structures discussions. This helps the management unit create a system for soliciting for better management structures necessary for improving service delivery.
As MacKian (2013, p. 32) observes, developing a working relationship with the stakeholder in the health care service delivery helps in the promotion of health status of the vulnerable groups and patients with acute health conditions. Similarly, stakeholder involvement in decision-making provides a prerequisite for gender equity approaches in management, thus playing an integral role in developing health policies that seek to implement the worldwide mission on affirmative action and gender equity. Developing partnership and increasing stakeholder engagement initiate active participation, empowerment, and public involvement in management decisions (Keating 2001, p. 44). In the process, it provides the public with the pleasures of owning the decision undertaken. In so doing, stakeholder engagement ensures significant address to pertinent health issues such as gender-based violence, social protection, maternal health care, and effective service delivery. Through co-ordinated stakeholder and public participation, health care institutions gain advantages in developing policies relevant to the public in question, thus standing great chances of offering service highly needed. Consultation provides avenues for adequate representation in decision-making and feedback systems, thus offering platforms for audits and management performance (McKee 2008, p. 38).
Principles of good governance
Independence sets out clear-cut objectivity in service delivery. It sets out measures necessary for employees in the health care service provider organisation to carry their duties without interference any decision-making body. To develop an independent system of service delivery, health care service practitioners must stick to their basic goal in the sector (Agere 2000, p. 46). Indulgence in any activity outside the health care service delivery structures as evident in the Mid Staff management unit, compromised the ability of employees to remain independent in decision-making. Independence requires appropriate and proportionate structure with an enhanced financial arrangement. In Mid Staff systems, however, the focus on the foundation trust mission ensured the acquisition of financial prowess without regard to the initial objectives of the institutions. Independence sets out measures to ensure employees of any organisation stick to the basic interests of the organisation (Stahl 2004, p. 22).
According to Calder (2008, p. 83), in any organisation, the ability of employees to take up responsibilities for every action undertaken earns public trust and ensures proper management of resources. The accountability principle in governance seeks to ensure compliance with the national and international laws based on the organisation resources and expected services. The stewardship of the funds in any health care service provider must ensure accountability of the employees though structured systems of billing for the services provided and adequate auditing of the resources after every financial year. When Mid Staff turned into financial trust in 2008, its focus changed from clinical health care provider to fundraising for the trust. Negligence from the employees, especially in the accidents and emergency department, coupled with management’s continuous disregard to the public outcry led to the failure of the financial institutions (Calder 2008, p. 97). Inadequate audit and financial report by the management ensures misuse of the resources in the organisation leading to its failure. Accountability ensures an adequate framework for public scrutiny with robust reviews of the quality of services. Accountability sets out clear whistle-blowing’ policy that ensures an organisation sticks to its mandate in service provision.
Openness and transparency
Openness and transparency as facets of good governance ensure consolidation of public and stakeholder confidence. Increased public confidence encourages stakeholder engagement in decision-making at all level of management in an organisation (Effross 2010, p. 48). As evident in the Mid Staff management system, openness and sincerity in service delivery were highly absent, leading to public mistrust of service. Diverted attention towards amassing financial resources for the trust deprived the management unit of the culture of openness and transparency. Insufficient and unclear records for decisions and actions taken up for implementation compromised the initial motive of the Mid Staff. In the end, the organisation went to its knees with the greatest health care scandal ever recorded. Apart from developing open policies and procedures for decision-making, openness and transparency in health care service delivery ensure clear recording of actions and decision with responsibilities. Equally, openness ensures availability of information to the public, hence providing platforms for oversight and audits. Openness and transparency play a vital role in inculcating a culture of good and ethical practices relevant to the basic mission of health care service providers (Stahl 2004, p. 27).
Maintaining objectivity, honesty, and selflessness seemed elusive among the Mid Staff employees. Failure to stick to the organisation’s original mission compromised level of probity and propriety in the execution of duties with the employee structures. In a scenario where the management unit loses objectivity in service delivery, productivity goes down, and effectiveness fails (Fewings 2013, p. 51). Integrity is a principle of good governance that ensures adequate fidelity to the basic driver and motive of an organisation. It ensures uttermost impartiality in all activities with all employees and proprietors within the systems declaring any form of conflicts of interest that might compromise service delivery (Kaplan, Dominis, Palen, and Quain 2013, p. 7). As evident in the Mid Staff scandal, the managing unit focused on the financial development of trust rather than initiating decisions for improving service delivery. The management of the accidents and emergency unit of the organisation continuously disregarded the governance principles relevant to enhancing public good. Accident and emergency victims died from neglect and irresponsible acts of the medical practitioners in the department. Developing an integrity policy in line with the national and international laws governing integrity in health care service remains vital in ensuring honesty, selflessness, and objectivity in service delivery (Fewings 2013, p. 53).
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Clarity of purpose
In this principle, health care services practitioners need to develop and communicate to the public clear and objective line of duty in the health care sector. Developing an independent scheme of work, with clearly defined boundaries of service helps the managed public and stakeholder expectations from the service providers (Calder 2008, p. 115). Mid Staff, as a health care service provider, had a service delivery mission. However, upon acquisition of the financial trust status in 2008, a change in the mission changed. The focus on financial stability compromised the clinical health service provision. Despite the management unit acknowledging this change, it failed to develop a new purpose for the public. The organisation continued to engage in service provision as the main activity despite all resource geared towards stabilising financial trust. Outright public cheating was evident in the organisation. Developing clearly defined goals and objective help an organisation regulate digression tendencies. Similarly, this principle helps in consolidating public and stakeholder trust within the organisation, thus providing a basis for successful service delivery (Agere 2000, p. 66).
Theories of leadership relevant to the case study
This theory argues that leadership capabilities draw inspiration from innate human characteristics. According to McEwan (2003, p. 81), personality traits such as intelligence, extroversion, affection, self-efficacy, open-mindedness, and transparency define the leadership characters of an individual within the position of power. Similarly, personal drive for achievement, motivation characteristics, self-confidence, and honesty among decision-maker improve their leadership capabilities. In the Mid Staff organisation, the management seemed to get inspiration from the desires for success but lacked the honesty, transparency, and compassion needed in health care. Their dishonesty necessitated the hiding behind service provision while the core driver of the organisation changed to financial prowess after 2008. The leaders lacked compassion and affection for the plight of the patients who continuously faced neglect as decision focused on improving financial stability (Zaccaro, Kemp, and Bader 2004, p. 125).
This focused on the behaviour of the leadership in the development and execution of decision (Clark 2009, p. 21). Aristocratic leaders impose a decision on workers and the stakeholder. Democratic leaders consult the public and affected individuals before implementing a decision while laissez-faire leaders take aback as the subjects and subordinates take decisions. In the behavioural perspective, Mid Staff management unit employed aristocracy in decision making with uttermost disregard to the public outcry. Consultation of the public and relevant stakeholders in decision-making remained absent as the managers focused on stabilising the trust fund at the expense of the public’s health needs (Zaccaro 2001, p. 62).
Recommendations and conclusions
The problems of Mid Staff arose from gross disregard to the ethics in service delivery, irresponsible management decision, and insufficient inclusion of the public and other various stakeholders in decision-making. Cultivation of transparency, accountability, honesty, and integrity among the management and subordinates at the Mid Staff remains the basis for righting the horrifying wrongs evident in the scandals.
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