Is the NHS a safer place a year after the Francis Report?

Imagine that today, 6 February 2014, you’ve just said goodbye to your elderly mum or dad, looking small, lost and confused in a hospital bed. They’ve been admitted after a fall at home and you’ve been told they’ll be in for a few days, and not to worry because they are in safe hands.

But you do worry, because you remember reading all those stories about what happened in Mid Staffordshire Hospital. You worry about whether, at 2am in a darkened ward, there isn’t something similar going happen to your mum or dad, if they won’t be given a drink, if they will have to lie in soiled sheets, if no one will answer their calls for assistance.

A year on from the publication of the report of the public inquiry into the Mid Staffordshire NHS Foundation Trust, what answer could the NHS ‘system’ give to this worried relative?

There were plenty of initiatives to engage staff at all levels of the hospital in discussions and debates about how to create and maintain a genuinely patient-centred culture

Understanding the impact of the Francis Inquiry Report on acute hospital trusts in England was the main research question we set ourselves last year, the findings of which are published today. The research was based on a short online survey of 53 acute trusts and in-depth interviews with 48 mostly senior staff at five acute trusts in England.

It was an inevitably self-selecting sample, but if our worried relative was using one of these hospitals, what we found might offer some reassurance. The important themes from the Francis Report had apparently been heard by the senior staff we spoke to.

For example, the Francis Inquiry (like the one before it) found that the board of Mid Staffordshire had been focused on financial matters at the expense of the quality of care being given to patients. Many of the senior staff we interviewed were almost militant in their insistence that quality of care must always be put ahead of financial considerations, even if it meant spending more on nurses and brought a stormy ride with commissioners and regulators.

Where the Francis Report had concluded that the board at Mid Staffordshire was blind to the failings in care happening within its own hospital walls, our interviewees described multiple initiatives to see and hear about all aspects of care, having real-time ward level data on falls, pressure sores and other metrics that signal poor care.

They described responding to complaints faster, in person and in more depth, and they described opening up different channels to communicate with staff and encouraging staff to speak up when things go wrong, in sharp contrast to the dismissive, bullying culture that had silenced staff in Mid Staffordshire.

Our interviewees had heard the message from the Francis Inquiry about the importance of changing culture within their trusts. This was a tougher challenge, because it takes time, and its success is harder to measure. But there were plenty of initiatives to engage staff at all levels of the hospital in discussions and debates about how to create and maintain a genuinely patient-centred culture.

But there were also aspects of what we were told that might be less reassuring for our anxious relative, about the behaviour of some of the external bodies – the commissioners, regulators and other managerial bodies – which were also the focus of the Francis Inquiry.

The interviews described their interactions with these agencies which, at times, could still feel punitive or blame seeking, still focused on meeting financial and other performance targets – particularly waiting times, like the A&E four hour target – which staff at all levels did not see as capturing ‘quality’ fully.

Interviews described an external system that required feeding with a massive amount of data to reassure both local and national bodies that care inside the hospital was safe.

Our worried relative, concerned abut their mum, might well think it was reasonable that the wider NHS system should have all the information about what’s happening inside each ward at their finger tips, and the power to knock heads together the minute things go wrong.

But the message of the Francis Report is that culture matters across the whole NHS: if the people running trusts feel too hounded by external bodies, the risk is that they won’t innovate or be able to create the blame-free culture that lies at the heart of a patient-centred hospital.

Because in the end, the only people who really know what’s going on at 2am on a hospital ward are the patients and the staff on that ward. Both need to feel able to speak up and be confident that they will be heard. Creating that open culture cannot be done in isolation in each hospital trust: it needs to be supported right through the NHS system.