Keogh report comes closer to recognizing the complex social dynamics of hospital practice

In my recent paper, Taking Organisational Complexity Seriously, I criticised Sir Robert Francis’s recommendations arising from his inquiry into the Mid-Staffordshire NHS Trust. I argued that these were too focused on “the system” and not enough on the everyday, local interactions between practitioners, patients and others through which outcomes emerge in practice. I suggested, that a better response might have been,

“… to encourage, assist and enable those involved to explore their current experience of their individual and collective practice: the situational specifics and taken-for-granted patterns of thought, feeling and behaviour that are organising that practice and which might tend to undermine the dedication and commitment that has long come to be associated with ‘the caring professions’”.

Thankfully, the subsequent review of practices in a number of other NHS Trusts by Sir Bruce Keogh seems to have adopted just such an approach – at least for the most part.  Most importantly, his recommendations appear to be focused on the specific needs of those staff in each hospital and Trust whose job it is to deliver the necessary quality of “clinical effectiveness, patient experience, and safety”. 

Although the shameful bickering and thinly disguised point-scoring that took place in the House of Commons in the immediate wake of the report’s publication might have suggested otherwise, the language in Keogh’s report is measured. And, pleasingly, his grasp of the complex nature of the dynamics involved in ensuring high-quality care is laid bare in his report:

“… our analysis of these 14 hospitals proves that understanding mortality (and concepts such as excess and avoidable deaths) is much more complex than studying a single hospital-level indicator. There are many different causes of high mortality and no ‘magic bullet’ for preventing it.”

In his covering letter to the Secretary of State for Health, Jeremy Hunt, he further seeks to debunk the idea that such abstract measures as the Summary Hospital-level Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio (HSMR) can be used to quantify actual numbers of “avoidable deaths” or to relate these to inadequate levels of care:

“However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths”.

Despite this, of course, this is precisely the use to which such measures have been put by politicians and media commentators alike!

So, at first sight, Keogh’s review offers the hope that more recognition might be given to the complex social reality of everyday hospital life through which care is ultimately provided. At the same time, though, he fails to challenge the need for the plethora of organisations that surround the provision of health-care services ‘on the ground’. In doing so, I feel that more emphasis is still likely to be placed on the checking-up of practitioners’ compliance with generalized rules and standards imposed by these 'arms-length' bodies than on helping them to deal with the specific realities that they face in the midst of ‘live’ practice.