All three reports are impressive works of expertise and insight. Like many, I was impressed by the breadth and rigour of Francis' analysis, by the clarity and focus of Keogh's ambitions, and by the absolute primacy given by Berwick to supporting and motivating staff. Most of us seem to agree with much of these reports' diagnoses of the problems and articulations of the goal we should be aiming for.
Where there is inevitably less agreement is over the actions required to get us there, and in particular, the role of central government and national agencies. Can you change culture from Whitehall?
The most obvious answer is no, of course not. Quality of care is first and foremost the responsibility of frontline staff, then of their leaders in trust boards and elsewhere, and only thirdly and finally the responsibility of national bodies. We have argued this in our response to the Care Quality Commission’s current consultation on its new approach.
Yet, recognising these limitations, the centre nevertheless has a role to play. The planned full government response to Francis is the opportunity for it to articulate and commit to this role. I think there are six broad things that the Department of Health and NHS England can and should do as a priority.
First, they can set the tone. A just and fair culture that trusts and supports staff, that puts the needs of patients above all else, and that welcomes criticism with a spirit of openness and enquiry rather than defensiveness, is something the top echelons of the DH and NHS England need to enact in everything they say and do.
Second, they can provide resources and training. Spreading the skills to lead for quality, to carry out quality improvement work, to involve patients in service design, and to analyse and use quality data, all needs investment in support, training and development. National agencies responsible for quality improvement have come and gone as much as any other structure in our constantly reorganised system, and have rarely been afforded the status and political commitment of other initiatives, and this needs to change.
Third, they can deliver transparency. Great strides are already taking place here, and while I am yet to be convinced that transparency will deliver significant improvement by helping patients make choices, or that the benefits of summary composite ratings will outweigh the pitfalls, it is true that the greater availability of timely, accurate, comparable data on quality is crucial to encourage and enable clinicians and organisations to continuously strive to improve.
Fourth, they can take some direct actions to improve how patients are listened to and involved in decisions. The degree of involvement in quality and safety issues afforded foundation trust governors, for example, remains in general a long way from what it could be.
Fifth, they can do more to ensure safe staffing levels. Like any structure or process target, simplistic, nationally-mandated levels that take insufficient account of local context will not work, but NICE guidance combined with greater external scrutiny on how it is being applied could help.
And finally, they can ensure clear, co-ordinated and proportionate responsibilities in accountability, assurance and enforcement. All staff, and patients, should be able to understand in five minutes what commissioners, regulators and national agencies are each responsible for. And as Berwick stressed, the government must require full co-ordination and co-operation between regulators to clarify and minimise their demands on the system. But regulation is a necessary and important final line of defence, and so as the CQC implements its new monitoring and inspection systems, they must be tested, researched and evaluated so that we can continue to refine the regulatory model.
This list doesn't add up to the creation of a safety culture – that is up to leaders, staff and patients to work together to deliver – but if the DH and NHS England deliver on these six areas over the next year and beyond, they would be making a significant contribution.