It is 10 years since the publication of the report by Sir Robert Francis KC of the Public Inquiry into Mid-Staffordshire NHS Foundation Trust. The inquiry explored major failures of care at Stafford Hospital that led to the unnecessary deaths of many patients, focusing on how this had been able to happen, why multiple warning signs were missed, and the changes needed to avoid a recurrence in the NHS.
Recommendations included fundamental standards of care to be assured to patients, sufficient levels of nursing staff, patient-centred leadership of the NHS, and an organisational culture (at all levels) of openness and candour.
We have had over 50 years of inquiries in the NHS, and Francis repeated many of the themes that echo down the years: hearing and heeding the patient voice; enabling staff to raise concerns with confidence; mitigating the risks of pressures in the health system; and an over-reliance on regulation and inspection as a ‘cure’. Ten years on from the Francis Report, has progress been made and what remains to be learned?
We have had over 50 years of inquiries in the NHS, and Francis repeated many of the themes that echo down the years: hearing and heeding the patient voice; enabling staff to raise concerns with confidence; mitigating the risks of pressures in the health system; and an over-reliance on regulation and inspection as a ‘cure’.Judith Smith, Professor of Health Policy and Management, Health Services Management Centre, University of Birmingham and Ruth Thorlby, Assistant Director of Policy, The Health Foundation, London
After Francis, national regulatory bodies for health care quality were strengthened, including the establishment of the Healthcare Safety Investigation Branch, and the Care Quality Commission (CQC) developing fundamental standards of care as key benchmarks for its inspections. Trusts are now expected to be more transparent about staffing levels by regular public reporting of local workforce data, including ‘red flag’ shifts with insufficient staff.
The NHS has introduced new ways in which staff can raise concerns or ‘whistle-blow’ where they fear harm is being done to patients or staff, although its implementation and effectiveness vary significantly. The ‘duty of candour’ called for by Francis is now in practice in the NHS, with doctors more ready to discuss with patients when things have gone wrong with their care, although more evidence of its effectiveness is still needed. At a corporate level, NHS trust boards are now expected to focus on quality and safety of care along with finance and be aware of the potential harms from dysfunctional organisational culture.
In other respects, lack of progress in response to the Francis Report has been disappointing. The NHS is still not listening properly or systematically to many patients and families and lacks deep curiosity about their insights and concerns. This is evidenced by maternity scandals, an inquiry into poor standards of mental health care, and major concerns about lack of attention to the needs of people with autism and/or learning disabilities within NHS care.
There does not yet appear to be a properly embedded NHS organisational culture of openness and transparency, as witnessed by the defensive behaviours reported where a ‘no noise’ approach is expected and service pressures may be downplayed or denied. There are well-documented staffing shortages and multiple vacancies across health and social care. A key lesson from Stafford was the importance of safe staffing and yet attempts to mandate staffing levels via NICE failed.
The COVID-19 crisis has intensified workforce pressures in the NHS and social care and brought serious delays for patients in accessing emergency care, along with historically long waiting lists for operations. Robert Francis himself has spoken out recently about what he considers to be a ‘system crisis’, noting the critical pressures on NHS and social care staff, lack of hospital bed capacity and implications for patient safety.
Looking back, our verdict on the NHS’ response to the Francis Report is that some progress has been made, but the diagnosis seems in many respects unchanged. Those leading and regulating the NHS at all levels must be able to hear, heed and speak up on behalf of the patients and families they serve. Without this, the NHS appears doomed to repeat many shameful failures of the past.
Judith Smith, Professor of Health Policy and Management, Health Services Management Centre, University of Birmingham and Ruth Thorlby, Assistant Director of Policy, The Health Foundation, London.