There seems to be a growing attitude that the Francis Report will not result in any great change. No doubt there will be a few worthy policies generated—although the amount of linked documentation is as likely to distract and irritate as it is to inspire more attentive caring. But any hope that it will be looked back on as a watershed event, a catalyst that inspired real change, seems to be increasingly fanciful.
One of the most challenging critiques I have read of the report is by Valerie Iles, “We need to talk about Francis” in her blog. She asks whether this was the right sort of public inquiry and whether Robert Francis QC was the right person to lead it. As a lawyer, Francis is trained to think in terms of right or wrong, guilty or innocent. Although he advised against scapegoating individuals and he tried to focus on the culture of healthcare, his legal background was evident in his approach. Imagine, for example, if the inquiry had been led by a philosopher or a historian? We might have been helped to think more clearly about the shifting paradigms and underlying philosophies that underpin the prevailing unhealthy culture. Was a legal mind what was needed? And what should inform such a decision?
It is helpful here to think about the different domains of knowing. The Cynefin framework (David Snowdon) for example, talks about the simple, the complicated, the complex, and the chaotic. It is important not to muddle up complicated, but knowable puzzles, where there are right and wrong ways of doing things, with complex and chaotic situations where there are no right answers, just better or worse ways of proceeding.
Many of the problems affecting healthcare delivery in the 21st century fall into the latter category, problems that require us—as complexity theorists put it—to muddle through as elegantly as possible. Our capacity to do this depends on qualities such as creative imagination, commitment to the truth, courage and professional wisdom—qualities that need to be grown and practised rather than prescribed. Whilst we can all apply our intelligence to how to nurture such qualities, there is little encouragement or reward in the present system for doing so. Such enquiry might take us to the heart of the system in a way that a lawyer is not equipped to do—even one as conscientious and humane as Robert Francis.
So much mishandling of the health service is down to a failure to correctly categorise the nature of the problematic situation, too often gravitating to the easier question and simplistic solution, fragmenting the system in the process, and avoiding the more fundamental and complex. Unless we get the questions and the nature of our enquiry right, we are doomed to ever more frantic “busy-ness”—more policies, more bureaucracy, more micromanagement, more lengthy exhaustive inquiries with prolific lists of recommendations. And more distraction from the task. In this sense, the Francis Report is part of the problem.
Penny Campling is a psychiatrist and psychotherapist and was a clinical director for many years. She has recently co-written a book entitled ‘Intelligent Kindness: reforming the culture of healthcare.’