NHS standards: what the Francis report means
Elliot Bidgood, 6 February 2013
The long-awaited Francis Report into failings at Mid Staffordshire NHS Foundation Trust was released this morning, analysing what went wrong and what we can perhaps do to prevent similar lapses in future (you can read it here). Here is a brief summary of what went on and of my tentative response to the report.
In 2005, the board of Mid Staffordshire General Hospitals NHS Trust, led by Chief Executive Martin Yeates, decided that the trust would pursue Foundation Trust (FT) status. To attain this status, trusts first have to demonstrate strong financial stability and meet clinical performance targets on measures such as waiting times. Mr Yeates and the Mid Staffs board therefore launched an initiative to hit the targets and dramatically cut costs, and the trust was subsequently granted FT status in February 2008. By 2009, however, it had come to light that the trust had a shockingly high death rate, the worst in the country – the trust had seen 400 to 1,200 more deaths than would be expected at an average NHS hospital in that time. Alongside this, horrifying stories emerged of understaffing, malpractice and extreme patient neglect. Complaints from patients and family members were seemingly ignored, and objections from staff were allegedly silenced with threats of dismissal. In 2007, local resident Julie Bailey was forced to establish ‘Cure the NHS’, a patients’ group dedicated to exposing the failures in Mid Staffordshire.
Multiple inquiries at varying levels have been conducted since 2009. This public inquiry, launched in June 2010, has called 290 witnesses and cost £13 million. It has raised questions in particular about the role of targets in the NHS, and the possibility that at times, they may perhaps be too much of a blunt, quantitative instrument to adequately ensure proper patient care. The four-hour A&E target, for example, allegedly led to cases where the order in which patients were treated was dictated by the target rather than by severity. In other incidents, patients were moved out of wards early and left to wait in other areas with inadequate equipment. In some cases, data on waiting times was simply falsified. Other problems were believed to stem from problems with understaffing, the result of the cuts that were made in order to meet the financial requirements. Some staff were undertrained, were unable to use equipment or were too junior to be handling the responsibilities left to them. In his letter to Health Secretary Jeremy Hunt accompanying the report, Francis summarised the lapses at Mid Staffs as follows:
“the story it tells is first and foremost of appalling suffering of many patients. This was primarily caused by a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.”
Francis also criticised the “culture” within Mid Staffs Trust, which he argued was “focused on doing the system’s business – not that of the patients”, had tended to “[ascribe] more weight to positive information about the service than to information capable of implying cause for concern” and included “too great a degree of tolerance of poor standards and of risk to patients”.
Since late last week, it has been known that one of the main strands of the report would be to recommend the strengthening of the NHS’s inspectorate, the Care Quality Commission (CQC), to prevent further oversight failures. Today, Francis wrote that that detection of and swift responses to poor standards of care, as could reasonably be expected by patients of the inspectors, simply “did not occur.” A former official at the CQC, Amanda Pollard, has testified that in its current state, the CQC would not “spot another Mid Staffordshire”. The report has recommended that checks should be tougher and more frequent, that CQC staff should have more training and clinical experience than they do at current and that the CQC should collect and collate a wider variety of relevant data, so as to make it easier to spot patterns of substandard care earlier. Francis also called for more information sharing between the CQC and other NHS bodies than there is at current and for the CQC to oversee “corporate governance” and “financial competence”, as well as quality.
These are all very important recommendations. A Panorama documentary in December featured the story of a whistle-blower at the Healthcare Commission (the pre-2009 predecessor to the CQC) who argued that the commission was understaffed and had to meet quotas for numbers of inspections performed, with the result that inspections were insufficiently thorough. Francis’ recommendation that the CQC be provided with a greater number of more experienced staff should go some way to remedying this, although it would also appear advisable that the system of rigid inspection quotas be relaxed, which Pollard specifically warned has led to “culture of bullying” within the CQC (a particularly eerie revelation, as it bears much resemblance to the bullying reported in Mid Staffordshire itself). The collation of information, meanwhile, would prevent worrying data from being overlooked, as was occurring at one stage of the crisis in 2007. Greater information-sharing would be another valuable lesson learnt, as at the point in time when the Department of Health was handing Mid Staffordshire its FT status, it was reportedly unaware of the Healthcare Commission’s coming investigation into the failures there.
Francis stressed that his report would also seek to “aid NHS managers”, though he pulled no punches in his assessment of some, warning that a “self-protecting elite refused to countenance complaints from patients and their relatives”. In the report itself, he has issued a recommendation that a “common code of ethics, standards and conduct” be drawn up for managers, “serious non-compliance” with which would make them unfit for duty. This perhaps aligns somewhat with the recent stance Health Secretary Jeremy Hunt has taken against governors and managers who fail on care quality – in November he argued in a speech at The King’s Fund that “just as a manager wouldn’t expect to keep their job if they lost control of finances, why should they if they lose control of care?”, making clear that this should be a grounds for dismissal. In his response to the report today, Prime Minister David Cameron reiterated this approach. Minsters have also speculated about the possibility of a blacklist of failed managers to prevent them remaining within the service. Significantly, Mike Farrar of the NHS Confederation, which represents NHS organisations and their managers, made clear in advance that the confederation understood the implications of the report, saying that “our failings in Mid Staffordshire will be laid bare – and rightly so” and that managers would work hard to put “patient-centred care” back at the heart of the NHS. He also agreed with the calls to sack failing managers and even appeared to endorse the idea of blacklists, arguing that “if people have completely failed they should not work in the NHS again”.
The report has also noted the role of Sir David Nicholson in the matter. Nicholson has been the chief executive of the NHS since September 2006 (and is now also chief executive of the new shadow NHS Commissioning Board Special Health Authority), but he was previously in charge of Staffordshire’s Strategic Health Authority between August 2005 and April 2006, part of the time when the failings were occurring. Some have already called on him to resign. However, Nicholson had argued that he should stay on to implement the report’s recommendations, something that should be seriously considered in light of his years of experience and the arguable need for continuity at a time when the NHS already faces substantial institutional instability in a number of respects, and The Guardian has reported that he retains strong support in Whitehall.
To all this, I would add that while Mid Staffs and other such scandals understandably have an emotive impact and we should seek to learn their lessons, we must also remember the brilliant job the vast majority of NHS staff do on a daily basis and be mindful of the fact that taken to excesses, “manager-bashing” is not constructive or good for morale in the service. Also, while the manner in which FT status was pursued at Mid Staffs was clearly wrong for the trust and its patients at the time, some in the press seem to have unfairly characterised the goal of the board there to achieve FT status as little more than a corrupt gravy train. In an article on Mid Staffs The Telegraph characterised the trust as wanting to make “the premier league” and summarised foundation hospitals to its readership as simply granting trusts “many freedoms from Whitehall, including over executive pay, and [the ability to hold] board meetings in secret”, a somewhat narrow and negative caricature. Under the right conditions, the benefits of allowing hospitals to be somewhat freer of central control, to be owned by their staff and local users, to take greater responsibility for their finances and to essentially run themselves as entrepreneurial non-profit social enterprises is not to be sneered at. 145 NHS organisations have successfully achieved FT status, and have in the main done so without scandals of the kind seen at Mid Staffs. One of the more favourable aspects of the coalition reorganisation coming this year is the aim to increase the number of trusts with FT status between now and 2014 as part of the ‘big society’ agenda, thereby limiting the two-tier distinction between trusts with and without this kind of autonomy and cooperative ownership.
The Francis report therefore poses huge questions for the NHS about quality of care and what needs to be done to maintain it, which I hope to explore in far greater detail later. But in the meantime, Francis has raised some starting recommendations as to how accountability, oversight and the overall culture of patient care in the NHS can be improved.
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