Feature / Plain speaking

The Francis report on Mid Staffordshire NHS Foundation Trust could have far-reaching consequences for the NHS. Seamus Ward summarises its findings and NHS reaction

This is becoming a landmark year for the NHS in England. The huge shift in commissioning responsibilities from 1 April alone could engender a feeling of substantial change, but the Francis report on Mid Staffordshire Hospital NHS Foundation Trust could have an equally big impact. Francis could affect every aspect of patient care – from how nurses are trained to the decision-making process for savings plans; from the skill mix of staff on a ward to the foundation trust assessment process.

That the Francis report lived up to its billing is beyond doubt. The build-up to its publication began in earnest on the weekend before its 5 February publication, with a survey warning that more than half of nurses believed their ward or unit was dangerously understaffed.

As he had done two years ago in his independent inquiry into care at the trust, QC Robert Francis outlined a catalogue of distressing, and in many cases avoidable, failures in patient care. Primarily, this had been due to the trust board failure to listen to patient concerns and correct deficiencies and its tolerance of a negative culture that allowed poor standards and clinical disengagement to go unchecked. This was partly driven by the board’s focus on national targets, the achievement of financial balance and its application for foundation status.

The trust had financial problems, but these were not seen as particularly notable at the time. He said: ‘I have no doubt that the economies imposed by the trust board, year after year, had a profound effect on the organisation’s ability to deliver a safe and effective service.’ It was ‘remarkable’ how little attention was paid to the impact of proposed savings on patient care, he said.

While Mr Francis did not criticise individuals – indeed, he said it would be counterproductive to single out scapegoats – he found widespread system failings had contributed to the Mid Staffs troubles. The Department of Health and strategic health authority were too remote from the services being delivered; primary care trusts did not have the capacity to ensure they were buying quality services; local clinicians did not raise concerns until it was too late; and when assessing the trust’s foundation application Monitor was not aware of the Healthcare Commission’s concerns about the trust.

The report makes 290 recommendations, that Mr Francis said would ensure ‘self interest and cost control’ were not put ahead of patients’ interests. The recommendations fell into five categories and some of his key proposals are noted below:

Fundamental standards and measures of compliance

• Develop a list of fundamental standards that must be met to permit any hospital service to continue.
• Causing death or serious harm to a patient through non compliance without reasonable excuse should be a criminal offence.
• The National Institute for Health and Clinical Excellence should produce standard procedures and guidance on complying with the fundamental standards. These should include evidence-based tools for establishing the staffing needs of each service.
• The standards should be policed by the Care Quality Commission (CQC).
• There should be a single regulator for corporate governance, financial competence, viability and care quality. Monitor’s responsibilities for FT authorisation, governance, financial sustainability and the fitness of directors, governors and equivalent senior officials should be transferred to the CQC.
• The NHS Litigation Authority should set more demanding levels of financial incentives in its risk management ratings to motivate trusts to reach level 3. There should be more effective sharing and recording of information.
• FT applicants should have to demonstrate they meet fundamental safety and quality standards, as well as the financial and governance requirements.

Openness and candour

• There should be a statutory duty to be truthful to patients where harm has or may have been caused.
• Staff should have a statutory duty to make their employers aware of such incidents.
• Trusts should be open and honest in their quality accounts, describing faults as well as successes. Deliberate obstruction of meeting these duties or deliberate deception of patients should be a criminal offence.
• It should be a criminal offence for trust directors to deliberately give misleading information to the public and regulators.
• The CQC should be responsible for policing these duties.
  

Improved support for compassionate, caring and committed nursing

• Entrants to nursing should be assessed for their aptitude to deliver and lead proper care and their commitment to patient welfare.
• Training standards must be developed to ensure qualified nurses can deliver compassionate care to a consistent level.
• Nurses should be given a stronger voice in leadership at organisation and ward level.
• All healthcare support workers should be regulated by a registration scheme.

Stronger healthcare leadership

• An NHS leadership college should be established to ensure there is a common culture, code of ethics and conduct among all current and potential future leaders. A leadership college accreditation scheme should be considered.
• A code of ethics for all senior staff should be produced, but apply to all NHS staff.
• There should be a fit and proper person test for NHS directors. Being guilty of a serious breach of the code of conduct should lead to disqualification from holding senior positions in the NHS.
• While registration could be performed by an existing regulator, the need for a separate entity should be kept under review. The need for such a management regulator would be informed by experience of the fit and proper persons test.
  

Information

• The public should be able to compare relative performance in providers’ compliance with standards.
• All healthcare providers should develop and publish real-time information on the performance of consultants and specialist teams in relation to mortality, morbidity, outcomes and patient satisfaction.
• Every provider should have a designated board member as chief information officer.
  

Government response

The government will respond in full in March, but its early thinking appears to be that it will adapt Francis’ recommendations. For example, prime minister David Cameron’s immediate reaction in the Commons was to announce the creation of a chief inspector of hospitals – a post not mentioned by Francis – within the CQC.

Francis’ call for a single body – the CQC – overseeing finance, governance and foundation trust authorisation was one of the most talked about recommendations. Monitor accepted its share of the responsibility for regulatory failures detailed in the report, but said it had learned from its mistakes. ‘Any further changes to the structure of regulation are necessarily a matter for government,’ it said.

However, there were suggestions from unnamed CQC sources that the regulator did not want to merge with Monitor. Subsequently, health secretary Jeremy Hunt was reported saying Monitor would survive in the post-Francis landscape. The CQC would focus on inspection, though it is unclear whether this will include any ongoing financial assessment – currently carried out by Monitor and SHAs/the NHS Trust Development Authority. Monitor would continue to act as an economic regulator – presumably including already planned new roles such as tariff setting – and have responsibility for taking enforcement action against failing trusts (those providing poor-quality care, as assessed by the CQC, and failing financially). Monitor chief executive David Bennett reportedly suggested it could have a role in regulating managers.

In his immediate response, Mr Cameron said the government had asked US health quality leader Don Berwick to advise on making zero harm to patients a reality across the NHS  – preventing bed sores, for example. The prime minister also revealed that NHS medical director Sir Bruce Keogh would review the hospitals with the highest mortality rates. Initially, five organisations that had been outliers for two years on the summary hospital-level mortality indicator (SHMI)

were identified, but a further nine were added to the final list – these had been outliers for two years based on the hospital standardised mortality ratio (HSMR). SHMIs were developed in response to the first Francis report, which recommended a review of hospital mortality indicators.

Mid Staffs chief executive Lyn Hill-Tout apologised unreservedly for the trust’s past failings. ‘There are many valuable lessons to be learned and our expectation is that the NHS, at every level and every individual, takes these lessons to heart and acts upon them,’ she said. The care at Stafford Hospital had improved with reduced mortality rates, low hospital-acquired infection rates and fewer serious complaints. But she added: ‘We know that we still do not get everything right all of the time and are not complacent. As Robert Francis has outlined, many important changes are needed in the NHS and particularly personal and collective responsibility for ensuring safe, good care to our patients.’

The reaction from NHS professional bodies and groups fitted the mood of a service that had been chastened. Royal College of Nursing chief executive and general secretary Peter Carter backed the report’s recommendations of the registration of healthcare assistants and greater openness, including whistleblowing. ‘The RCN is acutely aware it has real lessons to learn from how it supported members locally at Mid Staffs,’ he said. ‘Although we’ve already put in place numerous measures, we will look at the report in depth to see what other steps we can take to improve our effectiveness.’

NHS Confederation chief executive Mike Farrar welcomed the focus on changing the service culture rather than structures and the core objective of putting patients at the centre of the NHS. He said: ‘There will of course be practicalities, including cost effectiveness and whether all recommendations do what they say on the tin. But let's not lose sight of the big picture. This is an opportunity to make the NHS safer, more compassionate and fully accountable to the people it serves.’

King’s Fund policy director Anna Dixon welcomed the report, but warned change would not happen quickly. ‘Even if all 290 recommendations were implemented now, the fundamental shift in culture can only be achieved if patient care is put top of the agenda for boards and is the first responsibility of professionals working in the NHS. That will take time and commitment,’ she said.

But British Medical Association leader Mark Porter called for urgent action to develop a new NHS culture. ‘It’s not enough to say lessons must be learned. It is essential we all – politicians, NHS, doctors, managers, nurses, patient groups – work together to develop a different kind of service where the system will not tolerate poor quality of care,’ he said.

With Francis keen to avoid naming a scapegoat, some papers joined relatives of those who died at the hospital in calling for NHS Commissioning Board chief executive David Nicholson to resign or be sacked. The Daily Mail was at the forefront of the attacks – ‘Man with no shame’ screamed the paper’s front page the day after the Francis report was published. Sir David was chief executive of Shropshire and Staffordshire Strategic Health Authority (as well as West Midlands South and Birmingham and Black Country SHAs) from August 2005 to April 2006 and some said he and other senior managers should resign.

Sir David, who received repeated votes of confidence from both David Cameron and Jeremy Hunt, apologised for the ‘appalling events’ at Mid Staffordshire. But apologies were not enough, he said; the NHS had to move quickly after sober and sensitive reflection to ensure the failings were not repeated in other parts of the health service.

There was bad news for managers as a whole, when an Ipsos Mori poll found 52% of the public blamed managers for the poor care at Mid Staffs. Ministers were blamed by 16%, regulators by 11%. Only 3% blamed doctors and 7% nurses.

An earlier independent review of Mid Staffs for Monitor had warned the trust was clinically and financially unsustainable, even though it was providing safe care currently. The investigation found that in order to break even, the trust would need to make £53m of savings in five years (7% of its annual budget) and still require a £73m subsidy from the Department over the period. Monitor has assembled an expert group to assess how best to provide the trust’s services in the future. A BBC Freedom of Information request found in the past five years the number of patients opting to be treated at the trust has fallen by more than 50%, with annual income dropping by £3.7m.

In late February, Monitor started the process for putting Mid Staffordshire into administration – the first time for a foundation trust. As Healthcare Finance went to press, a report on options for the future provision of the trust’s services was being finalised.

Other news became immediately linked to Francis. Former United Lincolnshire Hospitals NHS Trust chief executive Gary Walker alleged he had been forced out of his job and gagged from speaking out about his concerns over patient safety. The Lincolnshire trust denied he is prevented from speaking out on patient safety issues, but the furore brought whistleblowing and gagging clauses in severance agreements into the spotlight. In response Mr Hunt wrote to the service to warn against using gagging clauses to prevent whistleblowing. ‘I would ask you to pay very serious heed to the warning from Mid Staffordshire that a culture which is legalistic and defensive in responding to reasonable challenges and concerns can all too easily permit the persistence of poor and unacceptable care,’ the letter said.

It also emerged that Staffordshire police were examining the Francis report to identify whether criminal charges should be made.

With the government set to respond to the report this month, it is likely Francis will shape much policy- and decision-making to come.