The Francis report and its aftermath Conor Davidson

Compassion Candour Training Assurance Culture Leadership

2001 First Annual Dr Foster guide shows that Stafford Hospital had a higher than expected HSMR at 108.

2006 Reports in the local press that hospital is in a ‘squalid state’ (after visit by Terence Deighton)

2007 June – Monitor begins the review of the Stafford Trust application for foundation status. July – Dr Foster Unit sends Trust a series of mortality alerts. Oct – First Royal College of Surgeons Report.

2008 Jan – 'Cure the NHS' campaign group set up Feb – Trust granted foundation status Mar – HCC launches investigation Video

2009 Mar – Healthcare Commission report published – Chair and Chief Exec resign July – Second Royal College of Surgeons report – Public enquiry (Francis I) announced by new sec of state Andy Burnham CHAOS KILLS UP TO 1200 IN ONE HOSPITAL

2010 Feb – Francis I published May – Coalition Government take power June – Andrew Lansley commissions Francis II

"an atmosphere of fear of adverse repercussions" "forceful style of management" "pressure to meet targets" "systemic failure of the provision of good care" "too few staff, or staff not sufficiently qualified to cope" "incontinent patients left in degrading conditions" "injury and loss of dignity, often in the final days of their lives" "delayed diagnosis" "constant strain of financial difficulties" "isolation from the wider NHS community" "lacked effective clinical governance"

2013 February – Francis report published July – Keogh report investigating 14 outlier trusts published August – Berwick NHS safety review published October – Ann Clwyd review of NHS complaints system published November – official government response to Francis report

Compassion At Stafford: – Soiled patients unattended – Call bells not answered – Patients being left without food and water – Extremely poor hygiene – Medication not administered properly – Lack of adequate heating – Failure to notice or respond to deteriorating conditions – Failure to listen to, take seriously and respond to concerns of relatives

Compassion Recommendations: Core values and fundamental standards** Aptitude test* Nurse training include 'at least 3 months' hands on care** Named nurses for patients** Regulation of Healthcare Support Workers Consider creating role of registered older people's nurse* NICE to recommend staffing levels** (but note Keogh on reported vs actual staffing levels)

Leadership At Stafford: Financial problems since 2003/04 Bullying management culture Board focused on achieving foundation trust status Ill thought-through staff cuts and service reconfigurations Dysfunctional consultant body

Leadership Recommendations: 'Fit & Proper' person test for directors** Leadership college* System of accreditation/training for leadership posts* DoH should do impact assessments before any structural change of the healthcare system*

Candour Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered. Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators. Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

Candour At Mid Staffs: Disregarded criticism Ineffectual complaints system Isolated from wider NHS No support for whistleblowers High HSMR blamed on coding error Falsified records in A&E

Candour Recommendations: More effective NHS complaints system** Statutory 'duty of candour' - to patients, public and regulators* Gagging clauses should be banned** Regulators should share information** Common information practices** Real time effective accessible data**

Assurance At Mid Staffs: Poorly developed audit/clinical governance systems Board unaware of situation on the ground Ignoring indicators of poor performance Failure of regulatory system

“The current NHS regulatory system is bewildering in its complexity” -Berwick report

Asssurance Recommendations: Fundamental/enhanced standards* Clear metrics on quality** (Note Keogh on mortality ratios) Fundamental standards should be rigorously enforced and to cause death or serious harm to a patient by noncompliance should be criminal offence** Single regulator Beefed up commissioners* Note role of medical training in assurance

Culture At Stafford: Early warning signs - shabby & dirty environment, unsmiling staff who were distracted by mobile phones, didn't answer buzzers promptly, didn't pick up litter Isolated 'timewarp' Toleration of mediocrity 'Keep your head down' Bullying Isolated 'Systems business' put over patients business

Culture Recommendations All of them! Focus on 'culture of caring' 'Cultural barometer' Vague points about values, teamwork, post discharge care Frustration at political interference in NHS Schwarz rounds Can cultural change be achieved through top down recommendations? “In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.” -Berwick report

Training Junior doctors in Stafford A&E and MAU (‘Beirut’) silenced Lack of value and support being given to frontline clinicians, particularly junior nurses and doctors…’their energy must be tapped not sapped’ Five of Keogh organisations having training monitored by GMC Deanery to visit local providers & report back to GMC Medical students & trainees to be surveyed All overseas doctors (inc EU nationals) need English language proficiency

The aftermath…

Run out of town

Placing the quality of patient care, especially patient safety, above all other aims. Engaging, empowering, and hearing patients and carers throughout the entire system and at all times. Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work. Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge. – Berwick report