He identifies a complex series of problems with the systems of quality assurance that resulted in the gross failings in care at Stafford Hospital. He analyses why the warning signs were not picked up by the board, regulators and others supervising the hospital. And he asks why these bodies did not act to tackle the problems more quickly and more urgently.
The report addresses at least three key issues that are essential to supporting the delivery of high-quality care: clear and robust accountability, openness and transparency, and effective regulation. While on the whole his recommendations to strengthen accountability and to increase transparency are to be welcomed, there is a risk that the many changes to regulation and the increasing threat of criminal prosecution will stymie the changes in culture he calls for.
He makes clear that assuring quality of care is the responsibility of boards and senior executives, and that staff caring for patients should speak up and act to address problems. As we have highlighted, in our article on preparing for the Francis report, these are the most important lines of defence against poor-quality care. His recommendation that there be a ‘fit and proper person’ test for board members and senior executives is proportionate. This, together with better training for board members and the use of high-quality, timely information on the quality of care, including qualitative information from complaints and feedback from users, will help to strengthen clinical governance in hospitals.
While the report concentrated on the failure of care in hospital, Francis makes clear that all medical professionals, particularly GPs, need to take responsibility for all of a patient’s care. It appears that local GPs in Stafford were slow to recognise the problems in their local trust; we need to understand the reasons for this and what support GPs need. His proposal that a senior clinician is identified who can take charge of a person’s care is especially important for vulnerable patients and those with complex conditions; our research on continuity of care has found that hospitals are still not designed to care for the increasing number of these patients. Putting an end to practices such as discharging patients in the middle of the night will also greatly improve the experience of care.
Francis also recognises the importance of openness and transparency – a theme which will appeal to the current Secretary of State, who has promoted the implementation of the friends and family test across the NHS and wants to see Ofsted-style ratings for hospitals. We would caution against a simplistic rating of the overall performance of a hospital which can mask differences in quality between specialties and even between wards. Francis proposes to strengthen quality accounts – a positive move – to ensure data is consistent, comparable and presents an honest account of the state of care provided by the organisation. He also recommends that more clinical data is available at the level of a specialty or service. Our own review of service-line management highlighted the need for real-time high-quality clinical data, but many trusts were a long way from achieving this.
As expected, Francis also promotes a stronger requirement for organisations and staff to speak openly and honestly when things go wrong. It is not clear whether the new legal duty of candour together with the potential for criminal prosecution for failing to be open and honest will support a culture of openness. There is a risk this could heighten fear among staff and result in defensive rather than open practice. More important are the quality of clinical leadership and the culture of the ward and team in which staff work.
Finally, Francis focuses on the changes he thinks are needed to the regulatory and assurance system. In general he suggests that commissioners have an important role in monitoring the quality of care they purchase for their local populations and for driving improvements beyond the basic standards upheld by the regulator. Whether clinical commissioning groups can succeed in this where their predecessors have failed remains to be seen. Many of the detailed recommendations give new responsibilities to regulators including NICE and the Care Quality Commission. The transfer of responsibilities for governance and authorisation from Monitor to CQC will require major organisational changes, some of which will require further legislation and in turn more resources and time. Francis himself acknowledges the risks of transition, organisational upheaval and loss of corporate memory. He suggests that these changes need to be planned and implemented incrementally. I agree.
Francis cannot be accused of being anything other than thorough. There is, however, a risk that the many recommendations in this report, even if implemented in full, will not change the culture in some organisations where indifference or fear leave staff disempowered and unable to care for patients with the empathy and compassion with which they would wish to be treated themselves. This is the real test for the NHS.
- See our analysis of the Francis Inquiry report
- Read our response to the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
- Catch up with the key reactions and comments on the Francis Inquiry report with our Storify feed
- See our work on creating the right culture of care