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Mid-Staffordshire Smith, Judith; Chambers, Naomi

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Download date: 30. Sep. 2021 The Political Quarterly, Vol. 90, No. 2, April–June 2019

Mid Staffordshire: a Case Study of Failed Governance and Leadership?

JUDITH SMITH AND NAOMI CHAMBERS

Abstract The public inquiry chaired by Robert Francis QC into failings of care at the Mid Staffordshire NHS Foundation Trust made 290 recommendations about matters including: standards of patient care in the National Health Service (NHS); organisational culture and leadership; the use of data and information; the need for greater openness; and compassionate and commit- ted nursing. In this paper, we argue that Mid Staffordshire represented a profound failure of governance and leadership. We use findings from a national research study to analyse the response made by the boards and leadership of NHS hospitals to the inquiry recommenda- tions, setting out the repertoire of board roles and behaviours required for the governance of safe and effective care. Keywords: public inquiries, healthcare boards, healthcare governance, Francis inquiry, lead- ership

their monitoring role ... and to examine why Background problems at the Trust were not identified 4 IN 2013, Sir Robert Francis QC published the sooner; and appropriate action taken’. report of the public inquiry into Mid The report of the public inquiry, the Fran- Staffordshire NHS Foundation Trust, setting cis report, set out 290 recommendations for out his conclusions about the failings in care various parts of the NHS at a local, regional which occurred at Stafford Hospital between and national level, and other recommenda- 2005 and 2009.1 The events in Stafford had tions for a wide range of national regulatory been brought to light initially through the and professional bodies including the Health sustained efforts and campaigning of a and Safety Executive, Care Quality Commis- patient and carers’ group called Cure the sion, and the Department of Health. The rec- NHS, and included many cases of shockingly ommendations were grouped into six poor nursing and medical care, particularly themes: common values; fundamental stan- for older people and those who were dying, dards; openness, transparency and candour; and also those treated in the hospital’s acci- compassionate, caring and committed nurs- dent and emergency department. Details of ing; strong patient-centred leadership; and the failings in care had been set out in a prior accurate, useful and relevant information. independent inquiry report also written by Some of the specific recommendations that Robert Francis, and the founder of Cure the have subsequently been implemented in the NHS, Julie Bailey, wrote her excoriating NHS include: regular monitoring and public account of what happened at Stafford Hospi- reporting of safe staffing standards in hospi- tal in a book From Ward to Whitehall: the tals; the requirement that clinicians and man- Disaster at Mid Staffs Hospital.2,3 The public agers work with a ‘duty of candour’ towards inquiry was established in 2010 by the patients and relatives, being honest and up incoming coalition government explicitly to front when mistakes have been made and/ explore ‘the operation of the commissioning, or harm has occurred; the establishment of supervisory and regulatory organisations and an NHS Leadership Academy to design and other agencies, including the culture and sys- deliver training and development to NHS tems of those organisations in relation to clinicians and managers about patient-

194 © The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA centred leadership; and extensive work to hospitals, and performance management of improve the nature, operation and effective- the organisation (the NHS foundation trust) ness of patient complaints procedures. was found by the Francis inquiry to be inad- equate. All of this arguably contributed to the pressure faced by those working in, and Governance and leadership at seeking to lead and govern, Stafford Hospi- tal. Stafford A further factor contributing to the weak- One of the most frequently heard questions ness in governance and leadership of Staf- about the events at Stafford Hospital is ‘how ford Hospital was the nature of its on earth was this able to happen?’. The sheer management team. The chief executive was number of patients, families and hospital in his first such role—district general hospi- staff (those who became ‘whistleblowers’) tals (DGHs) are often considered appropriate reporting poor care, and over such an as ‘first step’ chief executive roles, but given extended period of time, appears astonishing the complexity and isolation of some such in the context of a publicly funded national hospitals as outlined above, leading a DGH health system in a major developed nation. is arguably one of the toughest roles in the Robert Francis’ overall diagnosis of Stafford NHS. The wider executive team of Stafford was that there was ‘A culture focused on Hospital was described by the Francis report doing the system’s business—not that of the as being out of touch with patient and carer patients.’5 He pointed to a lack of compas- experience, and disconnected from the priori- sion amongst hospital staff, noting that ties and concerns of frontline staff. Indeed, many of them were disengaged from the the board of the hospital trust seemed more organisation, keeping quiet as they feared preoccupied with looking upwards to regu- getting into trouble. Francis also highlighted lators and performance management bodies a failure on the part of many professional (for example, pursuing the elite ‘foundation and patient groups (not Cure the NHS) to trust’ status on offer to high performing think sufficiently about the needs of patients, NHS organisations and achieving national and a concern that regulators appeared to waiting time and financial targets) rather miss what was most important for patients than looking inwards to its staff, patients and their families. Indeed, Francis identified and clinical services, or outwards to the pop- over fifty occasions where different health ulation of Stafford. organisations missed opportunities to spot Some critics of the public inquiry argue that and act upon the events that were taking Francis stopped short of pinning the blame place at Stafford Hospital. This all begs a for failures of care on any one person or very profound question about what had organisation. This was not in fact true. On the gone wrong with the governance and leader- day that the inquiry report was published in ship at Stafford. London, Francis said in his public statement: Stafford Hospital was in many respects an ‘What brought about this awful state of isolated organisation, situated on the periph- affairs? The trust board was weak. It did not ery of the NHS’ West Midlands and North listen sufficiently to its patients and staff or West Regions. As a district general hospital ensure the correction of deficiencies brought —one of many built in the late 1960s and to the Trust’s attention. It did not tackle the early 1970s following publication of Enoch tolerance of poor standards and the disen- Powell’s Hospital Plan and typically in rural gagement of senior clinical staff from manage- shire counties or on the outer rim of major rial and leadership responsibilities.’7 conurbations—Stafford was trying to pro- As well as the board, there was a wider vide a comprehensive range of local health failure of governance at Stafford Hospital services, yet struggling to attract and retain that contributed to the sustained lack of sufficient senior and specialised clinical staff, attention to the many examples of inade- and keep core facilities such as its accident quate care, disengaged staff, and unneces- and emergency department open on a sary deaths. There were many who held twenty-four-hour basis.6 It was not suffi- formal governance roles who just did not ciently networked with major teaching seem to notice what was unfolding at

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© The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 The Political Quarterly, Vol. 90, No. 2 Stafford, or if they did, failed to act on what any way, and especially not by blowing the they saw or heard. For example, NHS com- whistle on poor performance.9 missioners were funding care at Stafford as Reflecting on the Francis report in a man- part of contracts that set out quality stan- ner that resonates very clearly with the dards; senior doctors were undertaking a inquiry chair’s own analysis of what needed clinical audit of services in their hospital, to be done to try and address the conun- and all clinicians in the trust were subject to drum of organisational culture, Newdick professional codes of conduct which require and Danbury pointed to four issues that they the reporting of poor treatment of patients; considered to be critical. First, a need to universities and deaneries were assessing strengthen patients’ voice and influence Stafford as fit for training medical, nursing within the NHS, arguing that mechanisms and other students; local government scru- for patient involvement are deeply inade- tiny bodies failed to see the full picture; and quate and nowhere near as effective as the Monitor, the regulator, approved Stafford for former community health councils abolished foundation trust status—a decision that was in England in 2003, although it should be signed off by the Secretary of State for noted that they continue to exist in Wales. Health. It should be noted, however, that it Second, Newdick and Danbury underline was the NHS regulator the Healthcare Com- the importance and value of the duty of can- mission that eventually blew the public dour that Francis proposed for the NHS whistle on Stafford in a report published in (and which was accepted by the Department 2009, responding to concerns put to them by of Health and enshrined in statute). Their Cure the NHS. other two themes are interrelated, being those of NHS managerial culture with a The conundrum of ‘culture’ relentless focus on good news and denying failure, and then the Department of Health As with many other NHS public inquiries and political centre’s sometimes overbearing over the past fifty years, for example the treatment of NHS managers and boards.10 2000 Bristol inquiry into paediatric heart sur- These four dimensions have been analysed gery, ‘culture’ was identified by Francis as by the Francis inquiry’s adviser on NHS being problematic at Stafford and something organisation as having the potential to create needing to be attended to if such failures of damaging and negative health leadership care were to be avoided in future. When dis- culture, and when positive and appropriately cussing his public inquiry report after its focussed, to enable a positive, supportive, publication, Francis suggested that the nega- and compassionate working environment tive culture he identified at Stafford was and context.11 formed of a toxic mix of pressure (for exam- This analysis in 2013 concluded with the ple, targets, financial troubles), negative reac- following: ‘Get serious about strengthening tions to such pressure (such as fear, low patient voice at a local level in the NHS, morale, disengagement), resulting poor beha- implement a duty of candour with legal viour on the part of staff (for example, backing, support managers and boards to uncaring, bullying, keeping one’s head prioritise quality alongside their financial down), and then such behaviour becoming and other duties and make sure the political habitual (as in tolerating poor standards of centre treats NHS organisations and leaders care, denying problems, and taking comfort in a mature and respectful manner.’12 This from erroneous external reassurance).8 Fran- begs the vitally important question as to cis presented this series of cultural dimen- what has happened to NHS governance and sions as interconnected within a closed leadership in the six years following publica- circle. This was very reminiscent of the ‘club tion of the Francis report. Have the much culture’ described by Sir Ian Kennedy in his vaunted changes to organisational and man- report of the Bristol inquiry based on analy- agerial culture started to occur? Is patient sis by Smith and Ham of a hospital’s culture voice stronger than it was, and critically, are where the prevailing atmosphere was one of NHS boards feeling emboldened to prioritise fear and blame: you were either in or out, quality and safety of care alongside or even and were not expected to ‘rock the boat’ in over financial duties?

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The Political Quarterly, Vol. 90, No. 2 © The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 Table 1: Desirable characteristics of NHS What happened next? boards, as reported by national opinion To answer these and other questions about leaders in Chambers et al., 2018 what happened following the publication of the Francis report, and the setting out by the • Are palpably focused on patient care Department of Health of its formal response • Give priority to quality, safety and learn- ing for improvement and planned actions in Hard Truths: The Jour- • Are more problem-sensing than comfort- ney to Putting Patients First, the National seeking Institute of Health Research (NIHR) commis- • Know what is going on, for example wor- sioned a set of research studies in 2015, ries of patients, staff and regulators through its Policy Research Programme.13 • Receive timely data on patient and staff One of these studies focussed on changes in concerns board leadership of NHS organisations fol- • Hardwire quality improvement through lowing the Francis inquiry, and was commis- the organisation sioned from the Universities of Manchester • Support staff, heed concerns, and protect and Birmingham, and the Nuffield Trust and staff from negative pressures • Promote a healthy, compassionate and undertaken by the authors of this paper and 14 — well-governed culture others. The research which forms the • Use data and information as the basis for — basis of the analysis set out in this paper improvement aimed to explore how boards and senior leaders of NHS acute hospital trusts had sought to implement the recommendations on organisational leadership made following the Francis report, and to examine the board behaviours and leadership following intended and unintended effects of this. Fur- the Francis report, and was used as the basis thermore, the research aimed to uncover the for a national survey of board members of enablers and barriers to improving senior NHS hospital trusts in 2016, and the devel- leadership, and hence wider board and opment of a set of six in-depth case studies organisational culture in the NHS, in the of hospitals where their board and wider context of the often toxic and unhealthy leadership behaviours and culture were management cultures described in Bristol examined in depth in 2016–2017. and Stafford, among other inquiries. The national survey of board members of In scoping the research study, interviews NHS hospital organisations in 2016 elicited were undertaken with national health policy 381 responses, covering 90 per cent of NHS opinion leaders to elicit their views about acute services trusts. The findings of this sur- the desirable characteristics of healthcare vey are perhaps best summed up by a quo- boards. This built on a review of the aca- tation drawn from a free text response in the demic literature in this area and resulted in survey, made by an NHS non-executive the dimensions set out in Table 1. director: ‘The Francis report has acted as a The depiction of board characteristics in reminder of what sort of organisation we Table 1 is stark in how the dimensions of don’t want to be like, and continues to be a board behaviours diverge from what was reminder’. The survey revealed that follow- found and reported in the reports of the ing the publication of the Francis report in public inquiries in Bristol and Stafford. In 2013, NHS organisations had developed—or particular, they differ in their focus on rest- revised and extended—a raft of policies less curiosity, the use of data to ask impor- including those relating to the handling of tant questions about quality and safety, and patient complaints, serious incidents, seeking being assiduous in remaining very well con- patient feedback, and staff engagement. nected to the concerns and priorities of Indeed, whilst many board members patients, families, and staff, as well as to reported significant efforts to improve (and certainly not in preference to) national patient and carer experience, and the health regulators. This articulation of healthy engagement of staff, it was salutary to dis- board behaviours framed the NIHR study of cover that respondents to the survey

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© The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 The Political Quarterly, Vol. 90, No. 2 admitted that they knew more about what established by the Care Quality Commission was important to national regulators of the following the Francis inquiry. As noted NHS than they did about the priorities and above, attention had been paid to improving concerns of patients and staff. In this way, it policies about patient complaints and staff was clear that the overbearing nature of engagement, and finding ways to partner NHS management culture highlighted by with other organisations to try and improve Kennedy (in the Bristol inquiry) and Francis patient care. The Francis report had clearly was still alive and kicking—almost literally pricked the conscience of most NHS organi- in some cases—and that NHS hospital sations about the perils of letting care quality boards found themselves compelled to look and safety fall off a board’s radar, with some upwards to regulators more frequently than stating in the research that ‘there but for the inwards to their patients and staff. grace of God go others of us’. When asked in the research survey about What was clear from the research was that the main challenges facing their organisation, many NHS hospital board members were hospital board members identified: patient exercising leadership that—following the safety, trying to achieve financial balance, Francis report—appeared to be more visible dealing with the demands of regulators, to staff and patients. Quality was reported seeking to cope with workforce shortages by a majority of board members to trump and having to navigate poor relationships in finance on occasions where ‘push came to the local health economy. Indeed, a central shove’—something that was felt to have theme emerging in the research was the pro- been given validity and even authorisation found dilemma and tension experienced by by the findings and response to the Francis hospital boards in trying to balance care inquiry. Related to this, the research identi- quality and safety on the one hand, and fied a rise in the influence of the chief nurse financial sustainability on the other. Whilst on NHS boards, their voice being considered the Francis report had led hospital boards to more influential and powerful, particularly make significant investments in nurse staff- in relation to matters of care quality and ing levels on wards and in emergency patient safety. Furthermore, and unsurpris- departments, and many had also recruited ingly, it was found that a board with stabil- additional doctors to try and ensure patient ity of membership and lower turnover safety and care, it was clear that three years appeared to help it work in a unitary, and on from the inquiry publishing its conclu- yet healthily challenging, manner. Finally, sions, the NHS was struggling to hold this the research study revealed that those hospi- line. Increasing financial austerity across the tals with ‘outstanding’ or ‘good’ overall rat- public sector was being felt by NHS boards, ings from the Care Quality Commission had who, having invested in staff to address higher self-reported scores for emphasising a known points of stress and vulnerability for full range of board purposes, including: patient safety, were now feeling pressure holding to account; supporting the executive from above to stay within budget whilst team; building organisational reputation; coping with a rising demand for services. seeking and acting on the views of a wide Thus, the research survey painted a pic- range of stakeholders; and being effective in ture of NHS hospital boards that had largely reconciling the views of competing interests. regarded the Francis report as instructive, timely and helpful. These boards had responded to the report by increasing staff- How can the NHS have healthy ing levels in critical areas of their hospital, ensuring that the ‘duty of candour’ (for all governance and leadership? clinical staff in the NHS to be frank and The Francis report revealed an organisation in open with patients and families when some- Stafford that had completely lost its way in thing has gone wrong) recommended by relation to its governance and leadership, with Francis had been fully implemented, and tragic consequences for many patients, family working hard to ensure that their organisa- and staff. The board of the hospital was out tion was ‘well-led’ as required by the new of touch with what really mattered, namely standards for governance and leadership the quality and safety of patient care, the

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The Political Quarterly, Vol. 90, No. 2 © The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 concerns and needs of those using the hospi- research study, we suggest five key roles for tal’s services, and the pressures on staff healthcare boards. Set alongside our under- which, in turn, were fuelling an organisational standing of theories about effective healthcare culture that in many areas was becoming tox- board governance, we also propose a reper- ic, fearful and even dangerous. The research toire of associated dyadic behaviours for undertaken by the team from the Universities board members to adopt.15 Drawing from our of Manchester and Birmingham showed analysis of findings from the empirical study, encouraging progress across the NHS in some the five roles we propose are: the board as aspects of the inquiry’s recommendations. conscience, shock absorber, diplomat, sensor The climate in which the NHS is operating and coach. These roles and behaviours are has, however, become more difficult since summarised in Table 2 below. the publication of the Francis report in 2013. What then does this suite of roles and The National Audit Office has reported that behaviours comprise for hospital boards the combined deficit of health service provi- who are seeking to provide effective leader- der organisations in 2017–18 is £991 million; ship to their organisation? First, in relation staff vacancy levels across the NHS are run- to the role of the board as conscience of the ning at around 100,000. Significant variation organisation, NHS boards need to own the in the accessibility, quality and patient-cen- legacy of the Francis inquiry in respect of tredness of care, in levels of staff morale, upholding fundamental standards of care, and leadership capacity and capability, all and the principles of the NHS constitution persist and are now evidenced in Care Qual- even when the external context makes it dif- ity Commission inspection findings. NHS ficult to do so. This role of being the con- trusts face multiple, simultaneous and seem- science of the organisation includes leading ingly conflicting demands of ensuring finan- the development of a core set of values, cial balance, overcoming workforce deliberative and inclusive approaches to shortages, capitalising on the opportunities developing strategy and making priority-set- of new technologies, dealing with the pres- ting decisions, and using listening and ques- sures of population ill-health, and coping tioning behaviours. with the fragility of the social care sector— Second, a recurring theme in research into all of which add up to the need for a mas- NHS boards is the burden of external regula- sive change effort. There is also an unpre- tion and an often frenetic policy environment dictable wider political and social set of where new initiatives can appear to shower conditions: Brexit, populism, social media to down upon hospitals and their leaders. In name a few. We are living in an uneasy age. these circumstances, boards need also to act Given this challenging context, the analysis as a shock absorber for their staff. This of the leadership changes made by NHS hos- means absorbing the attention and challenge pital boards, and the reported behaviours, of multiple external bodies, probing where reasoning and responses of participants in the necessary, distilling the feedback into

Table 2: Proposed repertoire of roles and associated behaviours of NHS boards in the wake of Francis, Chambers et al., 2018

Role Behaviours Conscience: upholding the organisation’s mission Listening and questioning and the values of the NHS Shock Absorber: supporting staff in adverse Courageous and probing circumstances and through difficult times Diplomat: understanding and acknowledging Ambassadorial and curious different internal and external interests and perspectives Sensor: using diverse sources of data to detect Challenging and supportive and solve local problems Coach: setting ambitious aims, benchmarking Mentoring and inquiring services, and seeking continuous quality improvement

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© The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 The Political Quarterly, Vol. 90, No. 2 messages that can be used to guide and sup- handled or resolved by the leadership of NHS port changes, and sheltering staff from organisations—this requiring multiple skills unhelpful external ‘noise’. As the director of that are constantly held in tension—to enable organisational development at one of the the work of the board to be achieved in an case study sites in our NIHR research study appropriately sensitive and effective man- put it, ‘to filter all the nonsense that comes ner.16 The dyadic sets of board behaviours are from the outside’. This can include the adop- presented in this paper as a way of under- tion of appropriately courageous and prob- standing how some of these paradoxes and ing behaviours when communicating with tensions faced by healthcare boards can be external national bodies. managed in an appropriate and robust man- Third, we identified the role of the board ner. For example, this may entail a board con- as diplomat. This includes promoting the fronting the possibility of closing a popular reputation of the organisation using ambas- local service which it knows is not (and can- sadorial type behaviours. But it also entails not be made to be) clinically safe. These board having the curiosity and empathy to under- behaviours can be understood further within stand and acknowledge the full range of the theoretical framework of board gover- internal and external stakeholder interests nance and leadership developed in prior work and perspectives, and knowing how to relate by Chambers et al.17 to other providers and operate within the Thus it can be understood that board mem- local health and care economy. As a board bers face choices in different situations about secretary described it in our national survey: how to deploy their repertoire of leadership ‘Although the relationships with others in behaviours. In the circumstance of a board the local economy could not be said to be having a low appetite for risk, in its role of sen- “poor”, they are not necessarily helpful. sor it will need to seek out truths about perfor- What is lacking is system leadership to try mance. Then, using an agency theoretical to overcome individual agendas and encour- frame, the board’s dominant mode of beha- age collective thinking and action for the viour is likely to be challenging but also sup- benefit of patients.’ portive, to ensure management is not driven to Fourth is the role of the board as sensor, hide unpleasant facts about performance. In having more of a problem-sensing than a circumstances which call particularly for a comfort-seeking orientation when scrutinis- coaching role to encourage collective innova- ing, with skill and wisdom, an appropriate tion, improvement and striving for excellence, range of information, including qualitative the likely dominant behaviours of the board feedback on patient and staff experiences, as will be collaborative and inquiring, drawing well as maintaining a focus on key perfor- from a stewardship theoretical perspective. mance indicators. In working with managers In circumstances when the organisation needs and staff in the pursuit of better and safer to build a better external reputation and care, this includes exhibiting both challeng- improved local relationships, we would argue ing and supportive behaviours. that the board has to prioritise its role as diplo- Finally, with the imperative for service mat, and behaviours which demonstrate improvement and striving for excellence to curiosity and ambassadorship are called for. A ensure sustainable and clinically effective care, focus on high levels of staff engagement and it is clear that boards also have a valuable role long-term organisational sustainability indi- as coach, using the analogy of the sports coach. cates the importance of representation, collec- This involves setting ambition and direction, tive effort and sharing of risks, and the board assessing performance, and supporting staff, in as the conscience of the organisation, with lis- an inquiring, mentoring and collaborative way. tening and questioning behaviours coming to In the research study described above, this role the fore to reflect the stakeholder perspective. is best likely to be fulfilled when there is visibil- Finally, the board, acting as shock absorber to ity, stability and continuity in board member- ensure an internal and external equilibrium of ship, and board members are appropriately power interests, will need to be both probing trained and developed. and courageous. Their responses to the Francis It is clear from this research that a whole inquiry report as explored in our research for range of issues need to be contemporaneously the NIHR demonstrated some of this.

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The Political Quarterly, Vol. 90, No. 2 © The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 trust-january-2001-to-march-2009 (accessed 21 Conclusion May 2019). The legacy of the Francis inquiry has indeed 3 J. Bailey, From Ward to Whitehall: the disaster at been identified in some beneficial impacts on Mid Staffs Hospital, Stafford, Cure the NHS, the intentions and behaviours of senior hospi- 2012, p. 16. 4 Francis, Mid Staffordshire Report, introduction, tal managers and their boards. There contin- p. 10 and summary of findings, p. 64. ues, however, to be concern about variation in 5 Ibid., letter to the Secretary of State, p. 4. the quality and consistency of such leadership 6 E. Powell, The Hospital Plan, London, Depart- practices and in the current circumstances, ment of Health and Social Services, 1962. courage and diligence are required to create a 7 R. Francis, statement on the publication of the climate and culture for kind, safe and clini- report of the public inquiry into Mid Stafford- cally effective patient care. The deployment of shire NHS Foundation Trust, 2013; http://myc a comprehensive NHS board and senior lead- ouncil.oxfordshire.gov.uk/documents/s20021/ ership repertoire of roles and behaviours to HWB_MAR1413R03.pdf (accessed 21 May mirror the complexity of the management 2019). 8 R. Francis, ‘Lessons from Stafford’, presenta- task and the trickiness of the external environ- tion to conference, ‘The Francis Inquiry: creat- ment is required. ing the right culture of care’, 27 February 2013, We make a case for the difference that the London, the King’s Fund. dynamic and restless NHS board can make, 9 J. Smith and C. Ham, ‘An evaluative commen- if the failings of governance and leadership tary on health services management at Bristol: revealed by the Francis inquiry are to be setting key evidence in a wider normative con- avoided in the future. This builds on the text’, Bristol Royal Infirmary Inquiry, 2000. ‘ work of board governance scholars who 10 C. Newdick and C. Danbury, Culture, compas- sion and clinical neglect: probity in the NHS after have exposed the gap between the myths ’ and the realities of the work of boards in all Mid Staffordshire , Journal of Medical Ethics, vol. 41, no. 12, 2015, pp. 956–962, first published sectors, the variable discretionary effort of online, 2013; https://www.ncbi.nlm.nih.gov/ board members, and the impact of minimal- 18 pubmed/23704781 (accessed 21 May 2019). ist and maximalist board practices. In addi- 11 J. A. Smith, ‘The Francis Inquiry: from diagnosis tion, our proposed board leadership to treatment’, Journal of Medical Ethics,vol.41, repertoire reflects the notion that the lived no. 12, 2015, pp. 944–945, first published online, experiences of senior leaders in the NHS and 2013; https://jme.bmj.com/content/41/12/944? the ongoing challenges they face cannot be medethics-2013-101461v1= (accessed 21 May fitted neatly into traditional theoretical gov- 2019). ernance categories. Switching from one mode 12 Ibid. of behaviour to another according circum- 13 Department of Health, Hard Truths: The Journey to Putting Patients First, London, HMSO, 2013. stances may be important, but so too is the 14 N. Chambers et al., Responses to Francis: ability to deploy fully, across time, the roles Changes in Board Leadership and Governance in of the diligent board. Only if this happens Acute Hospitals in England since 2013, Univer- will we be able to assert that the chances of sity of Manchester, University of Birmingham ‘another Stafford’ have been reduced. and Nuffield Trust, 2018; https://www.birm ingham.ac.uk/Documents/college-social-sciences/ social-policy/Publications-HSMC/2018/Re Notes sponses-to-Francis-report-January-2018.pdf (ac- 1 R. Francis, Report of the Mid Staffordshire NHS cessed 21 May 2019). Foundation Trust Public Inquiry, London, 15 N. Chambers et al., Towards a Framework for HMSO, 2013; https://assets.publishing.ser Enhancing the Performance of NHS Boards: A Syn- vice.gov.uk/government/uploads/system/ thesis of the Evidence about Board Governance, Board uploads/attachment_data/file/279124/0947. Effectiveness and Board Development, Southampton, pdf (accessed 21 May 2019). National Institute of Health Research, Health Ser- 2 R. Francis, Independent Inquiry into Care Pro- vices and Delivery Research Programme, 2013; vided by Mid Staffordshire NHS Foundation Trust, https://www.ncbi.nlm.nih.gov/books/ January 2005–March 2009, vols. I–II, London, NBK259411/ (accessed 21 May 2019). HMSO, 2010; https://www.gov.uk/governme 16 Chambers et al., Responses to Francis. nt/publications/independent-inquiry-into-care- 17 Chambers et al., Towards a Framework. provided-by-mid-staffordshire-nhs-foundation- 18 Ibid.

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© The Authors 2019. The Political Quarterly © The Political Quarterly Publishing Co. Ltd. 2019 The Political Quarterly, Vol. 90, No. 2