The
long awaited Francis report published in February 2013 makes for compelling
reading. It comes at a time when many of us, healthcare professionals, have to
deal with ever increasing pressures to
cut costs while at the same time striving to
maintain quality in the care we provide our patients. It is important
for all of us to examine this report carefully and assimilate the key messages
from it.
BACKGROUND
Robert Francis QC was first commissioned in
July 2009 to chair a non-statutory inquiry in the then Mid Staffordshire
General Hospital NHS Trust. This was
triggered by the high mortality rates of the trust in 2007.The results of the first enquiry
published in February 2010 concluded
that there was a lack of basic care to patients across several wards and
departments. The Board was accused of being more interested in achieving FT
(Foundation Trust) status and concentrated more on statistics and reports than
the outcomes of patient experience. More importantly it was damning on the role
played by external organisations such as the PCT (Primary Care Trust) who had
not identified the concerns till the investigation by HCC (Health Care
Commission) in 2009. The enquiry recommended that Monitor de‑authorise the Mid Staffordshire NHS Foundation
Trust when the power came into effect and suggested that there should be a
public enquiry to investigate the issues highlighted in the first enquiry. The
Department of Health and the Trust Board accepted all the recommendations of
the first enquiry and the second enquiry, now a Public Enquiry was commissioned
by the Government under the leadership of Robert Francis QC in June 2010.This report was finally published in February
2013 this year and consisted of over 1000 pages of detailed analysis and
recommendations. The shorter 125 pages
of executive summary provide a good feel of the complete report.
THE REPORT
The report commences with a consideration of key warning signs of poor care that existed
in Mid Staffs that should have triggered corrective action but did not. The next section explores issues relating to governance and
culture of the Trust. This is followed by an examination of the role of patient and public involvement groups, the
commissioners, the SHA(Strategic Health Authority), and the regulators to understand
what went wrong and to consider the role of other organisations. The conclusion
of the report deals, with themes relevant for the present and future with
recommendations.
WARNING SIGNS
Robert
QC unearths a whole series of events which in itself should have triggered an
enquiry as early as 2004 with the loss of star rating when the Commission for Health Improvement
(CHI) re-rated the Trust, and it went from a three star trust to zero stars.
The HCC commissioned annual surveys of staff and patient opinion revealed that
the trust was in the worst performing
20% in the country. A whistle blowing incident involving a staff nurse’s report
in 2007 was also ignored. Against a background of problems the trust announced
staff cuts which was not questioned by the SHA. The HCC meanwhile was preparing to investigate claims
of poor care but did not know that at a national level the trust was being considered
for FT status .Finally, Monitor did not know about HCC’s impending
investigation until after it had given the FT status to the hospital in 2009. A
breathtaking series of incidents over a period of 5 years should have alerted someone, somewhere to the
magnitude of the problem unfolding
within the hospital walls, but unfortunately did not.
ANALYSIS OF EVIDENCE
The Inquiry report examines the role played by each
organisation on what they should have known and done in response to concerns
raised. It was critical of the trust board not
responding to the concerns that were raised to it, the SHA for raising these
concerns to the Department of Health (DoH) at the time of the FT application
and Monitor for awarding the FT status without properly assessing the trust’s
capability of delivering effective patient care. The lack of communication
between various organisations was highlighted as the key problem. Further the
report highlights the disconnect
between policy decisions being made and
their practical implementation. It has been rightly pointed out that the
setting of national standards in itself will not “catch” a Mid Staffordshire but it is more
importantly the establishment of robust and
effective methods to police those
standards, which will eventually prevent another mid Staffs occurring.
KEY RECOMMENDATIONS
The report makes 290 recommendations and the following are
some key ones.
A common culture made real throughout the
system-Openness, transparency and candour
The report highlights the need for changing the
current culture of fear to a culture
“where the only fear is the failure to uphold the fundamental standards and the
caring culture.” The recommendation is that it should be a criminal offence for any registered doctor
or nurse or allied health professional or director of a registered or
authorised organisation to obstruct the performance of these duties or
dishonestly or recklessly make an untruthful statement to a regulator.
Monitoring of compliance with fundamental standards
The importance of having clear and simple standards
that both providers and patients can understand has been highlighted. These
standards should be informed by an
evidence base and be effectively
measurable. The fundamental standards should be policed by a single regulator,
the CQC, monitoring both compliance and the governance and financial
sustainability. There is a recommendation that
NICE should produce evidence-based tools for establishing the staffing
needs of each service.
Enforcement of compliance with fundamental
standards
There is an expectation of zero tolerance; with
a service incapable of meeting fundamental
standards not being permitted to continue. Further, non-compliance with a
fundamental standard leading to death or serious harm of a patient should
result in prosecution of as a criminal offence, unless the provider or
individual concerned can show that it was not reasonably practical to avoid
this.
Effective complaints handling
A new recommendation has been
introduced for an independent
investigation of a complaint to be initiated by the provider trust under certain
circumstances such as if a complaint
amounts to an allegation of a serious untoward incident or a complaint raises
substantive issues of professional misconduct or the performance of senior
managers.
Applying for foundation trust status
There is an ongoing
recommendation for the merger of CQC and Monitor and numerous suggestions for tightening up the
process including physical inspection of
site by CQC prior to awarding FT status.
Accountability of board level directors
The report tackles the issue of lack of
accountability currently among board level directors. A finding that a person is not fit and proper to undertake the role of Director may henceforth disqualify them from being a director of any other healthcare
organisation and they could themselves
be also reported to the regulator.
Medical training and education
The report recommends that students and trainees
should not be placed in organisations which do not comply with the fundamental
standards. Further those charged with
overseeing and regulating these activities should now also make the protection
of patients their priority. The General Medical Council’s system of reviewing
the acceptability of the provision of training by healthcare providers must
include a review of the sufficiency of the numbers and skills of available
staff for the provision of training and to ensure patient safety in the course
of training.
Caring, compassionate and considerate nursing
The report has asked for an increased focus on a
culture of compassion and caring in nurse recruitment, training and education.
The report would like to see ward nurse managers work in a supervisory capacity
and not be office bound. The Nursing and
Midwifery Council should introduce a system of revalidation similar to that of
the GMC with a Responsible Officer for nursing in each trust. To tackle the
issues of poor care noted among elderly patients, one suggestion is to create a
new status of a registered older person’s nurse.
Quality accounts with information about an organisation’s compliance or non-compliance with the fundamental standards should be made available on each trust’s
website.
Robert QC has recommended that every
organisation should announce at the earliest , its plans on how it was going to
accept and implement the recommendations and within the year, publish a report
with its progress towards these recommendations.
It is important that we participate in these changes in our organisation
and make the improvements happen.
CONCLUSION
The Bristol enquiry
was a wakeup call to the medical profession and it was believed, at the time,
that lessons would be learnt. However this
do not appear to be the case and the Francis report proves
this. The word “hindsight” occurred at least
123 times in the transcript of the oral hearing
and “benefit of hindsight” 378 times.
Empowered with the “hindsight” provided by the lessons from the Bristol
enquiry and many others that followed, the Mid Staffs disaster should not have
happened. Yet we let it happen.
The Francis report is yet another wake up call
to professionals like us. As Robert Francis QC pointed out- the system cannot
make the change for the better, it is the individuals in the system that can.
Is there are a hospital near you or perhaps even yours who may be declared as
the next “Mid Staffs”? We need to be courageous to speak up and stand up for
the patients that we serve. The big question is ...will we?
Robert
Francis asks for a culture change in a climate fraught with tensions between
management and clinicians. Consultant morale is the lowest it has been in years
and not enough nurses can even be recruited into the posts. Further nursing
profession regulation, could potentially make the nursing profession
unattractive for new entrants. Talk of criminalising failure to deliver care
may only drive the offenders deeper into the woodwork. People will be less
likely to open up to their faults if they are afraid of being prosecuted. The
report talk about routing out the blaming culture but till that is really done
not much can be done about being open about mistakes. As the management would like to put it, it is
no longer a “no blame” culture but a “fair blame” culture-fair by whose
standards, one wonders.
We
have a government that has set targets for financial savings for healthcare
organisations. The management unprepared for these challenges will make changes
such as cutting manpower because that is the easiest way to save. Unless the
government has a rethink of its financial strategy for the NHS, no real change
can be made in the thinking or actions of the management. On the other hand,
one could argue that a well qualified management team could identify cost
cutting measures which do not sacrifice quality. The report’s recommendation to
provide accreditation for management post holders and holding them more
accountable for their performance may encourage individuals with the correct
credentials to apply for these posts. Too often, managers in such posts are not
specifically trained for them and tend learn more on the job rather than come
prepared to deliver an effective role.
The
Deaneries have been given a chance to influence the environment in which
training takes place and must grab this opportunity to make an impact. It can
only be a good thing for trainee doctors to be made aware of their
responsibility to report deficiencies in care as a cultural change started
amongst trainees is more likely to produce a next generation of doctors with a
conscience-a conscience that will ensure that they act on behalf of their
patients.
Far
too many organisations exist and each adds further bureaucratic barriers to the transfer of information. The
Francis report is welcomed as step in the right direction in highlighting this
issue. Particularly welcome was the suggestion to not embark on another
re-organisation but one wonders as to whether this will be followed.
While
all this make for gloomy reading, one does need to make the change that Robert
Francis has asked for in his report-patients are being treated poorly and as
doctors we have let it happen – we need to overcome our squabbles and professional
divides and fight this together.
The Francis Report is a compelling read and I
would advise every one of you to read it, if you have not done so already.
Dr MAKANI PURVA
Consultant Anaesthetist
Director of Medical Education
Hull and East Yorkshire Hospitals NHS
Trust
Hull
UK
