Mid Staffs: a failure of ‘fire alarms’?

By Dr Ruth Carlyle

The public inquiry into care at the Mid Staffordshire NHS Foundation Trust raises questions about the professional culture and the impact of placing targets over patient care. Considered from a political perspective, however, it also reflects a failure of political oversight.

Senior politicians responsible for public services have choices over the forms of oversight they use. McCubbins and Schwartz suggest that politicians may choose professional ‘police-patrol oversight’, or they may prefer less formal engagement with citizens and user groups to provide ‘fire-alarm oversight’ (1984: 167). In order to encourage ‘fire alarms’, politicians create mechanisms that allow interested citizens and voluntary groups to access information and to refer problems before they become disasters. In the NHS, I suggest that politicians have created a series of statutory public involvement institutions to act as ‘fire alarms’: Community Health Councils; Patient and Public Involvement Forums (PPI Forums); Local Involvement Networks; and, from 2013, local Healthwatch. Each of these institutions was made up of volunteers, supported by paid staff, with statutory rights to scrutinise services and to refer problems. Part of the story of Mid Staffs is the failure of the statutory public involvement institutions to raise alarms.

During the period covered by the Mid Staffs public inquiry first PPI Forums (2003-2008) and then Local Involvement Networks (2008-2013) were in place. The PPI Forum for the Stafford Hospital was criticised in the initial investigation by the Healthcare Commission for being too close to the hospital board to challenge the poor quality of patient care. Giving evidence to the public inquiry, the Secretary of State for that period indicated that he would have expected the PPI Forum to raise the alarm if there were problems with standards at Mid Staffs:

‘I would particularly have expected any concerns or issues in relation to Mid Staffordshire to have been highlighted by the local public involvement structure – the PPIF [PPI Forum] at that time – but to my knowledge nothing came through this channel either.’ Andy Burnham

The successors to PPI Forums, Local Involvement Networks, had a looser structure than their predecessors, working with local groups and individuals, rather than having a membership system. Staffordshire Local Involvement Network is criticised in the public inquiry for focussing on internal ‘squabbling’ during ‘the worst crisis any district hospital in the NHS can ever have known’.

At the opening of Chapter Six of the public inquiry report, Robert Francis states of statutory public involvement institutions that:

‘It might have been expected that concerns about the standards of service would have first become apparent through these channels. Such representatives and their organisations were intended to be accessible to patients and the general public and to have the means to identify concerns and communicate to those responsible for the management, oversight and regulation of providers. In practice, alarm bells were not rung by this route, or at least not sufficiently loudly to provoke any effective reaction.’

This comment suggests that Robert Francis expected that the statutory public involvement forums should have acted as ‘fire alarms’. In practice, it was not the state-funded public involvement bodies that raised the alarm, but a group of local people who established an independent campaign, Cure the NHS. In Stafford, local people were prepared to raise the alarm when the statutory public involvement institutions did not do so. The Mid Staffs story still reflects, however, the expectation that statutory public involvement institutions should have acted as ‘fire alarms’.

Whilst this is just one dimension to the Mid Staffs story, the failure of statutory public involvement institutions to raise the alarm may influence senior politicians’ choice of oversight mechanism in the future.


McCUBBINS, M.D., and SCHWARTZ, T., 1984. Congressional oversight overlooked: police patrols versus fire alarms. American Journal of Political Science, 28 (1), pp.165-179.

Dr Ruth Carlyle completed her PhD Sheepdog or watchdog? The role of statutory public involvement institutions in political management of the NHS, 1974-2010 at Birkbeck in 2012.  She works at Macmillan Cancer Support, currently as Head of Information, Financial and Work Support.