6 Feb 2014

NHS reform: a year on from the Francis report into Mid-Staffs, what has changed?

It seems longer than a year ago but it was on this day in 2013 that Robert Francis QC published his report into the Mid Staffordshire NHS Foundation Trust.

On a cold and grey February morning in the cold and grey QE11 Centre in Westminster, he delivered his damning verdict – there had been, he said, “failings at every level”.  It was a report regularly referred to as a turning point in the health service.

Robert Francis QC Publishes His Inquiry Into Mid Staffordshire Hospital

Now, a year later, it is fair enough to ask the question:  has anything changed in the NHS?  Have lessons been learned?

In fact, when I tweeted that question,  I had an @Jeremy_Hunt response saying “more 2 do but real changes on the frontline.  Hospital nurses up 2400, names above beds, & greater transparency”.

And in a speech yesterday afternoon, Mr Hunt expanded on this, saying there had been a “real shift in priorities”.  There are, he said, “new inspections, more nurses and a stronger voice for patients, with compassionate care starting to replace tick-box targets as the major focus on boards and wards”.

“We must,” he also said, “pay tribute to the hard work of NHS staff as well as the whistleblowers and patients’ champions who refused to be silenced.  It is their efforts that have made the Francis Inquiry a turning point in NHS history.”

Today, in a foreword to a report by the Nuffield Trust,  Mr Francis also pays tribute to NHS staff.

He says: “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.”

It was something that quite patently needed to be said.

Over the past year, NHS staff I have spoken to have often been in despair at the fall out from Mid-Staffs.  They have felt that the rhetoric from ministers and, yes, the media has been relentlessly negative, as if what happened on those wards at that trust was happening on all wards at every trust.

This was exacerbated by the number of government-commissioned reports that followed Francis:  the Keogh mortality review; the Berwick review into patient safety; the Clwyd/Hart review into patient complaints; the bureaucracy and regulatory review by the NHS Confederation; the Cavendish Report into healthcare assisstants and support workers; the Nuffield Trust Ratings review; and the Chief Nursing Officer’s review into compassion in Practice.  Phew.

All of them contained some harsh criticisms, and yet it was not difficult to find examples of good practice.

At Kingston Hospital last November we filmed volunteers who come in every day to help at meal times and chat to lonely patients. As we arrived, very sadly, a patient had died and several of the nurses were in tears.  Their compassion and caring was positively visible.  (We didn’t film that for obvious reasons).

See my report from November 2013:  Mid-Staffs report – Francis welcomes government’s response

Yet on the wards there is still anger, too, that so much attention was paid to the behaviour of some of the nurses at Mid-Staffs and a few of the doctors, but that little was said about the trust’s board or management and their role in failing to acknowledge and remedy the serious problems there.

We know, of course, that the chief executive at the hospital at the time, consistently refused to give evidence to both Mid-Staffs inquiries.

And on the question of whistleblowers, there is still evidence that some trusts are ignoring the concerns of staff or that staff, themselves, still do not feel they can speak out when they see a problem.


However, the Nuffield Trust’s The Francis Report: one year on says that before Francis “candour” was a term unfamiliar to many staff.

Some of the trusts surveyed for the Nuffield report said they had refreshed their whistleblowing policy, while others had undertaken a fundamental review of how they handle complaints.

But one chief executive said:

“I still get anonymous letters from staff, raising concerns, which begs the question for me, ‘Why do you feel that you need to behave anonymously? You must be concerned that something would happen to you if we knew who you were’.’”

The over-arching theme of this section is that genuine culture change is a slow process.

Budget cuts

All of this comes at a time, too, when the NHS is under considerable financial pressure. One-third of England’s trusts predict they will be in debt by the end of next month.

The Nuffield report says there is now a tension between what can best be described as the Nicholson Challenge (to save £20bn) and the Francis Challenge to improve the quality and standards of care.

What is a chief executive or the chair of a trust to do when faced with staff shortages and a big debt?

This was one response:

“We had an interesting thing last year where, in our plan, to hit the savings – we had a million pounds, I think – to close a ward. And the board decided not to close the ward. We didn’t half get beaten up. [The] chair of the SHA [strategic health authority] …  gave me a bollocking for not hitting our control total.

“We, as a responsible board said,‘We cannot, in conscience, take a ward out of this hospital.’ But [the chief executive] got called to brutal meetings; I got called to brutal meetings. So, when they talk about the pressure on trusts, it’s still there.”

A&E crisis

And what about A&E and the four hour target?

The report quotes one manager as saying that missing targets and poor quality care may not be the same thing.

“We are giving good-quality care here,” the manager said.  “Yes, we are not hitting targets but … I’ve managed A&E now for three years and I can hand on heart go down there and know that we are giving good care to patients, and good care can take longer than four hours.”

What the Nuffield report does not reach is a meaningful conclusion, not least because a year is not long enough.

This is a report from one third of hospital trusts, and it states that what remains to be seen is whether the Francis report will result in measurably improved care for patients, and how extensive this is across hospital trusts generally.

In other words, it could be summarised with a phrase banned in most newsrooms: “only time will tell.”

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