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The Francis Report: one year on

The response of acute trusts in England

One year after the publication of my report of the Public Inquiry into the Mid Staffordshire NHS Foundation Trust, there is a natural interest in what progress has been made in implementing the recommendations made in the report. This new Nuffield Trust research, with which I have been happy to be associated, provides helpful insights into how hospital trusts have responded.

It is reassuring to see that in large part the respondents to this research appear to have embraced the need to learn from the two inquiries in Stafford and the alarming events that they described. Rightly, many did not wait for the public inquiry report to begin making necessary changes, but exploited the learning available from the earlier report. Over the last year the health service has been confronted not only with the Public Inquiry report, and the governmental responses to it, but also by a welter of subsequent reports and reviews. These include Don Berwick’s review into patient safety, Sir Bruce Keogh’s mortality review, Anne Clwyd and Professor Tricia Hart’s review into NHS complaints, and Camilla Cavendish’s health care assistants review. It is therefore not surprising that only a start has been made in considering the necessary changes at local level.

Remarkably, all but a very few of the Public Inquiry’s recommendations were accepted in full by the Department of Health, and all were in principle. The strong message thereby sent out to the health service by government was that important and fundamental change was required. This message has been reinforced by the words and actions not only of the Secretary of State personally, but by other NHS leaders.

What does this research tell us about what is actually happening closer to the front line? It is not surprising that many were shocked by the findings of the two inquiries and realised that changes were required to prevent similar events occurring in their own organisations. The persisting belief of some that the events reported were unique and unlikely to occur elsewhere is worrying. This is a dangerous misapprehension which is disproved by the findings of the Keogh review, among other recent reports. Importantly, poor standards were not found everywhere in the Mid Staffordshire NHS Foundation Trust; some good services were provided. The finding of good practice in some parts of a hospital is no guarantee that all is well everywhere. The vast majority of front-line staff, who are consistently hard-working, conscientious and compassionate, have to understand that criticism of poor and unacceptable practice is not aimed at them but is part of a struggle to support everything they stand for.

The general acceptance shown by this report that quality needs to be given much greater priority is very welcome, as is the recognition of the need for support of a high standard of front-line leadership, and better engagement of the talents and knowledge of front-line staff. Likewise there appears to be a widespread agreement that improvement is needed in the information made available on the effectiveness of the service provided. Many hospitals report now being engaged in trying to bring this about. The need for openness, transparency and candour seem to be generally accepted, and this research shows that front-line organisations do not have to wait for instructions from above to make positive progress in this regard. For too long, too many in the health service have been inhibited in doing the right thing for patients by feeling obliged to wait to be told what to do.

Some respondents found the public inquiry report of “challenging” and “unhelpful” length and that the recommendations lacked prioritisation. The problems uncovered are not however amenable to simplistic, one-off solutions. Therefore it is inevitable that widespread change was called for. To the extent that there is a consensus around the Inquiry recommendations, whatever their number, it is surely incumbent on leaders at all levels to devise programmes for their implementation and an order of priority. Some respondents in this research report that national bodies have persisted in some of the behaviours towards hospitals that evidently contributed to the problems identified by the two inquiries. This is a theme echoed coincidentally in the recent Point of Care Foundation report (Point of Care Foundation, 2014). Although the Nuffield Trust research is based on a relatively small number of interviews, the inconsistency of approach between regulators that some interviewees spoke of is of concern. Similarly it appears that some commissioners at least have yet to get to grips with their responsibilities with regard to quality. If all this is true, it would suggest that a lack of coordination and elements of the system-based culture so evident in the regulation and oversight of Mid Staffordshire have persisted in spite of the assertions to the contrary by the regulators. Changing this requires their immediate and constant attention.

Perhaps of most concern are the reports suggesting a persistence of somewhat oppressive reactions to reports of problems in meeting financial and other corporate requirements. It is vital that national bodies exemplify in their own practice the change of cultural values which all seem to agree is needed in the health service. This may mean a reconsideration of the expression of priorities, behaviour and language, and the reaction to the inevitable tension between finance and quality that will arise in some trusts.

If it is impossible, even with good practice, to provide the service required within the resources allocated then it is incumbent on leaders to communicate that openly to those responsible for commissioning and funding services. That then needs to lead to a frank discussion about what needs to be provided within the available resources and what cannot. It is unacceptable to pretend that all can be provided to an acceptable standard when that is not true.

Undertaking the necessary culture change in the NHS was never going to be easy or a short one-off task. Only time will tell whether the obvious enthusiasm for change demonstrated by hospitals taking part in this research, can translate into the relevant action. Regular reviews will be needed to monitor progress.