Financial pressures and a complex regulatory environment are making it difficult for hospitals to create the kind of patient-centred culture recommended by Robert Francis QC, according to new research by health think tank the Nuffield Trust. But senior NHS staff interviewed for the research said that the 2013 Francis Report had added impetus to their efforts to put quality of care as their top priority.
The research, published on the day of the first anniversary of the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, is the first look at how hospitals have responded to the findings and recommendations contained in Robert Francis QC’s report.
It draws on in-depth interviews with around 50 staff at five acute hospital trusts and an online survey of chairs and chief executives at more than a third (53) of acute and foundation trusts in England. Together these provide a snapshot of the impact of the Francis Inquiry.
The one good thing Francis has done, the really good thing, is that it has ensured that safety and quality have become more prominent – that’s really important Hospital chair
Robert Francis QC, who acted as an advisor to the research, has written a foreword to the study.
The research found that many of the themes from the Francis Inquiry Report, including the importance of openness, adequate staffing levels and patient-centred culture, have resonated with leaders of the hospitals responding to the survey and interviews.
Four in five (82 per cent) of the hospitals responding to the online survey said they were taking new action in response to the report, and an even greater proportion (93 per cent) said they already had work underway on many of the relevant recommendations when the report was published.
In the interviews, senior NHS staff said that the 2013 Francis Report has added impetus to their efforts to put quality of care as their top priority, despite the straitened financial conditions facing the NHS, with one leader stating that "I’d rather be hung for money than for quality and safety".
However, hospital leaders described how meeting financial goals and ensuring safe staffing levels in hospitals was very difficult and will only get harder in the future. As one hospital chair said:
"The one good thing Francis has done, the really good thing, is that it has ensured that safety and quality have become more prominent – that’s really important. But I am left with a real concern about the do-ability of it all and the need for us to find a way forward."
The research also found that some hospital boards were finding it hard to meet increased demands for assurance and scrutiny from external regulators and commissioners that have arisen since the Francis Report.
Leaders often described a burdensome regulatory approach that seemed to be at odds with, and could distract from, their efforts to develop an open quality-focused culture in their own organisations. One leader told the Nuffield Trust that "I’ve never, in my whole career, felt more regulated."
Commenting on the Nuffield Trust’s research, Robert Francis QC, said:
"It is reassuring to see that in large part the respondents to this research appear to have embraced the need to learn from the two inquiries into Stafford and the alarming events which they described. In particular there appears to be general acceptance that quality needs to be given a much greater priority.
"It is concerning, however, that some respondents reported that national bodies have persisted in some of the behaviours towards hospitals that evidently contributed to the problems identified by the two inquiries.
"If true, it would suggest that the lack of co-ordination and elements of the system-based culture so evident in the regulation and oversight of Mid Staffordshire have persisted in spite of the assertions to the contrary by the regulators.
"It is vital that national bodies exemplify in their own practice the change of cultural values which all seem to agree is needed in the NHS."
The study notes that while hospitals are being encouraged to use ‘cultural barometers’ to assess the health of their own organisations, there is no similar mechanism in place to assess the behaviour and functioning of the wider NHS system.
Ruth Thorlby, report lead author and Senior Fellow in Health Policy at the Nuffield Trust, said:
"Our analysis provides a glimpse into the activity and views of around one-third of hospital trusts. Many of the themes and recommendations of the Francis Inquiry have been recognised by the staff we interviewed and the trusts taking part in this study appear to be making efforts to change their organisational culture, understand the quality of care and hear more clearly the views of staff and patients.
"But many of the strategies being used to improve quality, such as boosting nursing numbers, are resource intensive and hospitals are also under huge financial pressure.
"Some of the interviews suggested that hospitals are involved in exacting interactions with commissioners and regulators, which have also responded to the Francis Inquiry findings by seeking increased assurance that quality and efficiency are being delivered by hospital trusts.
"It is important that these interactions between hospitals and the wider NHS system are conducted in a fair and responsible manner, and that there is some independent and evidence-based way of establishing whether the dysfunctional relationships amongst the regulatory and commissioning bodies and between them and hospitals described in the Francis Inquiry have been rectified and improved."
Notes to editors
- The Nuffield Trust is hosting a major conference to mark the anniversary of the Francis Inquiry Report, with speakers including Robert Francis QC and the Rt. Hon. Stephen Dorrell MP.
- The quality of patient care is a core theme of the Nuffield Trust’s work. In partnership with the Health Foundation, the Nuffield Trust has launched QualityWatch, a major research programme providing independent scrutiny into how the quality of health and social care is changing over time.