In June 2010 the Government asked Robert Francis QC to undertake a public inquiry into the role that commissioning, supervisory and regulatory bodies played in monitoring the work of Mid Staffordshire NHS Foundation Trust. The final report of The Mid Staffordshire NHS Foundation Trust Public Inquiry (the Inquiry) – chaired by Robert Francis QC, was published on Wednesday 6 February 2013. The product of nearly three years’ work, it runs to three volumes with almost 1,800 pages and it has 290 recommendations.
The report exposes the appalling suffering of patients at Stafford Hospital, many of whom died through neglect. The focus on meeting NHS targets and achieving financial balance took precedence over patient care. The Trust lost sight of its fundamental responsibility to provide safe care.
The report is critical of multiple external healthcare organisations whose scrutiny failed to detect systemic and sustained failures which occurred over a long period of time and which had widespread and grave impact on patients. The report examines what information was known which might have been expected to give cause for concern or further enquiry. However, it concludes that the primary responsibility for the unacceptable standards of care lay with the Trust Board and professional staff. The report also concludes that the Trust Board did not sufficiently listen to its patients and staff and failed to tackle a negative culture involving tolerance of poor standards and disengagement from managerial and leadership responsibilities.
The Board received an overview of the Francis Report at its April board meeting and there were updates on progress at its December Board. The Trust has reviewed the recommendations of the report and has provided an overview of the number that are relevant to the acute trust with reference to the key themes outlined in the Francis report. In addition, the Trust has reviewed the five domains outlined in ‘Patients First and Foremost’, the Government’s initial response to the Inquiry and its five point plan, as a framework to support an initial analysis.
- Recommendations / key areas of change outlined in the Francis report
- The Government's response
- Overview of trust actions
The Public Inquiry makes 290 recommendations across five key themes:
- clearly understood fundamental standards and measures of compliance
- openness, transparency and candour throughout the system
- improved support for compassionate and committed nursing
- strong and patient centred healthcare leadership
- accurate, useful and relevant information.
Approximately 120 recommendations apply to the acute hospital setting, or will impact in terms of reforms and changes, which as a result, we may be required to undertake as an organisation. Numerous recommendations focus on expectations that most patients consider should be automatic and basic to their care, i.e. professionally endorsed and evidence-based means of compliance with fundamental standards, in which the needs of patients are paramount.
Key recommendations that will ensure that the patient is put first and is the first priority in all that we do include:
- Foster a common culture, shared by all in the service, of putting the patient first.
- Focus on the culture of compassionate caring and value care and compassion as much as treatment
- Ensure openness, transparency and candour throughout the system and be honest about failure
- The fundamental culture change required does not need further disruptive reorganisations – but it does need major changes within the current system
- Develop a set of fundamental standards, with clear means of enforcement
- The healthcare regulator to focus on policing compliance of standards
- All those providing care for patients to be properly accountable and that the public is protected from those not fit to provide a service
- Proper accountability for senior managers and leaders to protect the interest of patients
- Enhance the recruitment, education, training and support of all the key contributors to healthcare, in particular nursing and leadership positions
- Recruiting for values
- Develop and share ever-improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for patients, the public and all stakeholders in the system.
The Government made its initial response to the Inquiry in March in ‘Patients First and Foremost’. The response sets out a plan around 5 domains to revolutionise the care that people receive from the NHS and to put an end to failure:
- Preventing problems
- Detecting problems quickly
- Taking action promptly
- Ensuring robust accountability
- Ensuring Staff are trained and motivated.
The response is a call to action to work towards excellence. The most notable interventions within the five domains are:
- Appointment of a Chief Inspector of Hospitals - will shine a powerful light on the culture of hospitals to identify and tackle poor care
- A 1/3 reduction in paperwork, box ticking and duplication in terms of regulation to enable time to care
- Safety in the DNA of the NHS – The Berwick Review to ensure a robust safety culture and a zero tolerance to avoidable harm
- Introduction of ratings for hospitals – a single balanced version of the truth similar to the OFSTED approach
- Statutory duty of candour
- Complaints review
- Implementation of fundamental standards beneath which the quality of care must never fall
- Failure regime for quality
- Health and Safety Executive to use criminal sanctions
- Faster professional regulation
- Barring mechanism for failed NHS managers
- Healthcare Support Worker experience prior to access to nursing degrees
- Code of Conduct for Healthcare Support Workers.
The Secretary of State for Health requires all healthcare organisations set out publicly how they intend to respond to the Inquiry’s conclusions by the 31 December 2013:
The depth and breadth of the recommendations and interventions outlined in the Francis Report are immense. The Secretary of State has acknowledged this by giving organisations until the end of 2013 to review and consider their approach prior to the publication of their formal response.
This paper provides a high level overview of learning from Francis and it outlines the key areas of focus and interventions from the Government’s initial response to Francis and the Trust actions that have already taken place since the publication of the Francis report or that are in train.
The Trust will have a robust and detailed action plan with an up-to-date report on progress which will include a strengthened approach to:
- Public engagement and patient experience - we will further develop and build on our existing channels for engaging, involving and communicating with patients, the public and staff so we listen to what they are telling us and use their feedback and suggestions to help us continually improve quality. This year we have run our first patient panels where we are getting feedback on the care that we are delivering. In addition we are undertaking 15 Steps walk around with our Governors and the public so that they can give us feedback on the ward environment and how welcoming it is.
- Effective complaints handling procedures - there is currently a national review of the way the NHS handles complaints. We will continue the work we have already begun to review and revise the way we handle and learn from complaints to ensure that issues are addressed in an appropriate and effective manner and that the same problems do not keep re-occurring. We will move the PALS office so that it is more accessible for our patients and the public. In early 2014 we will be conducting an external review of complaints and looking at the both the RCA process and how to better involve patients in the process. Despite the number of complaints reducing the trust is meeting with more families than ever to better resolve their issues and to learn and improve the care that we give.
- Quality assurance – a review of approaches to assuring on the quality of service provision is already underway which has been externally validated.
- Risk and incident management - building on existing risk profiling and learning lessons from risk data and incidents. The Trust is strengthening its governance team to ensure that all risks are understood and appropriate management actions are in place.
- Workforce - we will further develop the education and training of our staff to ensure they have the right knowledge and skills, understand the priorities and expectations of them and demonstrate the right values. This includes partnering with the Open University in a number of areas particularly targeted towards Health Care Assistants. The Trust has invested more than £2m in medical nursing staff this is to ensure that minimum staffing are met or exceeded and we are working towards the recommendation within the Keogh Report on 24x7 working.
- Organisational Culture - based around the Trust’s existing culture and values programme, WeCARE, and the external view of the Trust’s culture. This programme was put together following engagement and consultation with both staff and patients.
- Rewarding and recognising good practice - we will further develop our systems for this, whether it’s by individual staff, a team/department or the whole Trust and we will continue to tackle any areas of poor practice and hold people accountable for their actions. We have developed ways of measuring care at ward level which is reviewed monthly by the Board and on available to the public on every ward. At the end of the financial year we planning to celebrate high performing ward areas. All members of staff that have been recognised by the public as having provided exceptional service are written to by the CEO to celebrate their achievement.
We will also look at additional ways of incorporating patient stories, staff stories and other personal feedback into quality reporting to the Trust Board, Council of Governors and other similar forums.
Everything that has been outlined above has the single, common aim of ensuring we have the right priorities, are assessing and continually improving the quality of our care, and that we are delivering the best possible outcomes for our patients.
The strategy which is currently under development will set clear priorities, expectations and actions around the standard of care patients and their relatives can expect from us. There will also be clear lines of accountability and responsibility.