Building a culture of compassionate care in the NHS

The long-awaited report from Robert Francis QC was published today. The families of those whose loved ones suffered or died in the care of Stafford Hospital today received an apology from the Prime Minister, but no heads have rolled. Despite calls from campaigning groups for action to be taken against the individuals who were in charge at the time, Francis has resisted blaming individuals. Instead he focuses on what can be learnt from the appalling events documented in this and earlier reports.

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.

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#40019 Daniel Steenstra
Professor of Medical Innovation

After the Francis report it is clear that in order to change the culture the NHS requires leaders that are compassionate and driven by quality of care. The evidence shows that Sir David is not, otherwise Mid-Staffordshire e.a. would not have happened. Considering that people seldom change their motives and values, Sir David would not be able to lead the NHS to a better future, an even more important reason for him to go than accountability.

Furthermore, in my opinion the Big5 management consultancies are partially responsible for the current culture in the NHS. See for example Part I, sec 1.122 of Francis report: "by the time of the review of the 2006/07 year, KPMG, the Trust’s external auditor, reported that it had successfully delivered on the action plan to remedy these concerns". Many Trust boards relied on advice of these financial hatchet men to get Foundation Trust status. In my experience of talking with senior partners in the Big5 they ‘chase the money’ without proper consideration for patient care. This led to Trusts focussing on financial processes and systems ignoring their core activity of providing healthcare. Trust ‘leaders’ were not sophisticated enough to manage this and balance the input of the management consultancies with providing healthcare.

#40020 Dr Kadiyali M S...

I liked Proff Steenstra's comment "NHS requires leaders that are compassionate and driven by quality of care" but does he know what happens to doctors who were compassionate and caring? They are hounded, harassed, bullied and driven insane.

Now the report is out, your organisation is asking questions. What were they doing when doctors like me contacted your organisation?

#40021 Mike Stone

Surely the main change, has to be for staff to openly report and consider the comments from the patients and relatives who are actually on the wards ? Isn't this - actual real-time feedback from patients and relatives, commenting on 'care, etc' - what Francis said was totally ignored at Mid Staffs ?

This 'professionals alone consider the problems' isn't the answer to this one - it is the professionals, who created the mess ! You need to make sure that staff who raise concerns, cannot be 'bullied', as well !

#40022 mel conway
consultant in public health

Why has there been no mention of the role of government ministers and policy in reference to NHS culture? Is it possible that politicians telling the public that they can expect choice, timely access to the latest inovations and drugs, and guaranteed excellent outcomes at the same time as setting stringent cuts (calling them efficiency savings) and telling staff (managers and clinicians) to just make it happen, could have an adverse effect on culture, morale, job control, scope of clinical responsibility etc?

The NHS does not just have one 'culture' to change.

#40023 Helen Lewis
Lay representative in emerging Surrey CCG

Missing from the Francis Report, as far as I can see, is recognition that because an avalanche of anecdotal evidence from patients or carers was needed for the NHS even to notice, we need a move right away from the NHS research model that says rigorous 'clinical' evidence is the only kind we recognise, if we really want to give proper value to patients' and carers' stories.

Dr Helen Lewis (non-medical), a Surrey CCG member

#40024 Harry Longman
Chief Executive
Patient Access

Thought provoking. My feeling on Francis is that there is a lot of motherhood which we all know about. Changes of "culture" will have everyone spouting the new political correctness, but with the same people in change, the same thinking and the same system, the opportunity for sustainable change has been missed.

#40026 Sholom Glouberman
Patients' Assocation of Canada

I agree with Helen Lewis. But would add that a stronger and more effective patient voice is needed in the NHS. The report has only one recommendation (number 62) about this and only at far remove from the individual organizations. Patients and families have direct experience of care and their experience must be listened to and values in every part of the NHS. Without a persistent patient voice the scandal might have passed unnoticed. Moreover waiting for terrible mortality figures for "evidence" seems wildly out of place.

#40027 Values in Healthcare
International Charter for Human Values in Healthcare

The culture must change. It's about values. Dignity, respect, kindness, partnership with patients/families --all universal human values -- are essential to effective and safe healthcare.

We have established an international collaborative effort to restore human values—including listening and hearing-- to healthcare around the world. This effort has resulted in the International Charter for Human Values in Healthcare. The Charter's mission is to restore the universal core values that should be present in every healthcare interaction – to healthcare around the world.

#40030 Mike Stone

Isn’t the point , made explicit by Francis, that the problems at Mid staffs were hidden in plain sight ?

It isn’t as if there were not doctors and nurses who couldn’t see what was happening, or that the hospital did not have managers who ought to have been able to see – similarly there were ineffective bodies intended to represent patients, and various regulatory bodies that were also ineffective. This seems to have been a combination of:

1) Very little actual power to change things at ward level;

2) People distant from actual patients, concentrating on their own individualised/specialised objectives, with the result that hierarchical structures ‘failed to see the wood for the trees’.

Creating more, or altered, ‘records-dependent box-ticking structures’ isn’t going to solve this problem: what has to happen, is:

3) Nurses must be told to honestly listen to patient feedback (good and bad, but not Ad Hominem – that needs a different process), and be empowered to report on that feedback up to Board level (possibly via a ‘Culture Champion’ representative);

4) The nurses who report, must be reporting ‘for the nursing body as a whole’, so that bullying/silencing is effectively impossible;

5) These comments from patients and their relatives, reported by the nursing body to the management, must also be openly published, so that lay users of hospitals can see what previous users experienced.

It makes little sense to tell nurses and doctors that they have a professional duty to raise concerns, when so many have either had, or read of, clinicians who highlight these problems being ‘bullied’ – separating the ‘bad news’ from the ‘messenger’, is a necessary step if it is ‘stuff from above’ that is being criticised ‘to those above’. Reporting a concern, should not be akin to going over the top at The Somme !

So, I think I agree with Helen Lewis above - verbal comments from patients/relatives, and staff-to-staff verbal discussions, might not be all that easy to 'record and measure', but surely they are critical to 'cultural evaluation' ? Talk more, listen more, be more honest and open.

#40031 JIm Edwards
sexual health outreach
NHS Isle of Wight

There is an article in the latest Public Service.Co .UK magazine entitled " Francis puts a bomb under the marketisation of the NHS and that seems about right to me. Every organisatition seems to be reacting to this report by agreeing how terrible the situation at Stafford was and agreeing with all the recommendations except the ones which directly threaten their own organisations. The RCN say they don't agree with the idea of separating their union function and their professional body status (even though they obviously cannot perform both roles without contradicting themselves - do they represent staff interests or patient interests?) The Foundation Trust Network agrees with everything EXCEPT the parts which threaten the idea of local autonomy (which is most of the report in one way or another) and the parts which call for national mandatory standards to be imposed and inspected from above. My own Trust (which is striving to acheive Founation status at the moment) is "appalled" by the revelations from Stafford, but goes on in their statement to say that this is in no-way typical of the NHS as a whole - somewhat missing the point I think?
Bring back a nationally agreed Blueprint for public healthcare delivery and properly accountable mechanisms for maintaining and enforcing the quality of its delivery. Staff will then be happier because they will know what is expected of them and will feel part of one unified national project. The NHS is at war with itself at the moment.

#40032 Mike Nicholls

I was a county councilor for 20 years and for much of that time I was responsible- for social care and health matters. During that time the NHS went through four major reorganizations, not to mention sideshows such as PFI.

What took place at North Staffs is not excusable under any circumstances, but the fiddling of politicians of all parties,over the years, has certainly aggravated the situation.

So on average there was a reorganization every five years. It took at least 12 months for the new system to bed in and by the fourth year there was talk of yet another reorganization the NHS was in permanent turmoil much of it brought about by political dogma. Added to this was what can only be described as management by fear. On the ground this resulted in departmental managers being told to cut their budgets but at the same time significantly increase the number of patients treated. If the manager had the temerity to ask, "How can this be done?". The answer came back,"That is up to you, if you can't do it I will find somebody who can." Now I was always taught, never ask anyone to do anything you can't do yourself. We should not be surprised if staff, fearing for their jobs tried to paper over the cracks, in this atmosphere of perpetual turmoil.

This is not a plea for no change, but it is a plea for organic change in the services that are provided and in the way they are provided. It must be around twenty years ago that Rowntree Foundation-suggested that many elderly people were in hospital simply because there was nowhere else for them to go. A situation that has persisted until now, when some progress i being made. The important thing is to address the needs of the patient and not the needs of management. It is undoubtedly true that the hospital service is top heavy and it is necessary to simplify management. One area that it is right to question is the modern trend for box ticking. One sometimes feels that there are people, who on being shown a new hospital wing will not believe in its existence, until they have seen the tick in the box.

What took place at North Staffs is not excusable under any circumstances, but the fiddling of politicians over the years has certainly aggravated the situation.

#40036 Mike Stone

40031 JIm Edwards

'Every organisatition seems to be reacting to this report by agreeing how terrible the situation at Stafford was and agreeing with all the recommendations except the ones which directly threaten their own organisations.'

There seems to be a general law, that individuals and bodies, can identify failings in others, more easily than their own failings.

40032 Mike Nicholls

'One sometimes feels that there are people, who on being shown a new hospital wing will not believe in its existence, until they have seen the tick in the box.'

The NHS is obsessed with 'process and form-filling'. Someone writing in The Times yesterday, commented that the Board of Mid Staffs regarded reports of bad treatment from patients or relatives 'as anecdotal, and therefore worthless'.

This 'unless it has been recorded somewhere, it did not happen' mindset is also used in complaints investigations - 'tick-box' is complex, but the 'mindset' at present is too simplistic and too extreme against 'direct, relatively informal, face-to-face verbal feedback in real-time', as compared to 'formalised processes/meetings'.


#40037 Jagdeesh Singh ...
GP/Education Director
The Productivity Centre

Yes to cultural change.
How to achieve it?
First - consider barriers to speaking openly:
Nursing and Medical Directors need to take steps to ensure they have built a network and a power base outside of the organisation so that they 1. have non-positional sources of power at their disposal 2. they are less susceptible to latent or explicit threats to their livelihood/reputation for fear of raising concerns and championing the coal-face clinician on the ward.
Practical skills in engaging in supportive but challenging conversations - with the CEO, the Finance Director, the NCB - can help.
Next, we need to STOP feeding the beast in order to focus on feeding the patient. Patients turn into widgets due to the proliferation of non-value adding paperwork at the bedside that is supposed to assure 'the board of quality' but which has nothing to do with care of the patient in front.
Instead, build metrics that support the work of the front-line clinician and aggregate this information to feed up to the board. Get rid of any admin that doesn't support the clinician-patient interaction.
Glad we have this debate, thanks to Francis, and desperately want the conversation to continue and actions to flow from it....

#40038 kathy fellows
District Nurse (retired night service)

How on earth have we arrived at this state of affairs in our once admired NHS?
Every day/night of my career I loved with a passion. My basic training gave me the foundation of which stays with me to this day. Reassure
your patient was drummed into us, time was spent with them.
Every ward manager/sister involved in any way should be struck off and sacked. If criminal charges are needed, so be it. No manager has ever had any affect on my care, looking after my staff, making clinical decisions. I am frustrated and angry that the rule of nobody's should be allowed and they need to be got rid of.
The majority of staff must be so saddened and must be helped to carry on doing their job, with support and backup

#40039 Medifix

This is because the managers assumed they can manage to offer care using the algorithms. Please check out my youtube videos, you will understand

#40040 Dr Sri

I have listed 50 questions that you need to ask, only then will you know how and why things went from bad to worse. Doctors like me have stopped working and left the country because we are ashamed for not nipping this in the bud

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