I find it interesting that the Keogh Report found failures in care at 14 hospitals, 11 of which have been put into special measures. We now know none of the 14 has been given a clean bill of health and that then raises the possibility that there are other failing hospitals out there.  The 14 investigated in this review were a snapshot of poor performers chosen because they had the worst death rates for the past two years.

The key question for me being how was this allowed to happen given the role of the Care Quality Commission (CQC) and the leadership within each of the hospitals and their associated trusts? For me there is a fundamental dilemma between care and business. Basically the NHS will spend as much as it is given on caring if it were allowed to do so. However it is seen as a bottomless pit by the Treasury and those responsible for funding it. The clash of the two cultures, care and frugality, needs to be addressed by strong and decisive leadership to maintain the necessary and somewhat precarious balance in an affordable and efficient way. The issue being exposed in the media at the present is the current lack of balance with either one of the two cultures gaining supremacy. If the care side wins Trusts go broke if the business side does people die unnecessarily.

The real leadership dilemma is how does the government maintain standards at an affordable level? It has tried to do this from without using the CQC to maintain the standards and this has now been proven to be a flawed process although the government will maintain and enhance that philosophy with the appointment of Sir Michael Richards and his army of inspectors.

The real problem is not going to be changed from without, the problem is a cultural one and the clash of cultures within the NHS and culture can only be transformed through strong leadership throughout an organisation and a clear and unambiguous strategy that is understood and bought into by those who work within it. This cultural change has to be driven internally by great leaders. Cultural change cannot be driven from without the organisation. I believe the government should be investing in the leadership within the NHS rather than repeating its previous error of unsuccessfully imposing change from outside an organisation. Culture is after all “how people do things round here when no one is looking” and during inspections someone is looking.

The challenge now for the NHS and those in charge of monitoring it – the regulators, NHS England and the government – is to identify exactly how widespread poor performance is and how they can then deliver the necessary cultural balance to drive the required improvement in standards in an affordable way through strong and effective internal leadership.

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