Four years ago I published a report laying bare the shocking care provided at Stafford Hospital. I heard of an elderly patient left naked in public view covered in faeces, of another who died because she not given insulin, of wards where elderly patients were not helped with food and drink, of an A&E where waiting times were fabricated.
Staff who raised genuine concerns were not listened to or respected, and patients and their families were not told the truth about had happened.
A year ago today I published my report of the public inquiry into what these issues implied for the system as a whole. I found a weak leadership had given priority to cost control, meeting targets, corporate governance and the promotion of a reassuring image ahead of patients and their safety.
Staff gave up raising concerns about patients, preferring to avoid trouble and keep their heads down.
The persistent belief that events at Stafford were unique and unlikely to occur elsewhere is dangerous and wrong
In the wider NHS, good news was not evaluated critically, and bad news was ignored or discounted. Corporate memory and continuity were lost through reorganisations and lack of staff retention. Poor managers were not held to account. Well-intentioned national policies were understood as demands to be met at all costs.
To repeat these uncomfortable truths is not to attack the high quality treatment provided by hard-working and committed staff. Proper recognition of their right to insist on the best standards will let them protect patients.
Encouragingly, since then the Health Secretary, the NHS Medical Director, and the Care Quality Commission (CQC), among others, have led the way in starting many necessary reforms.
We can see much greater readiness to admit and address problems about care, an enthusiasm for effectively measuring how good services are and whether there are enough staff. Improvements are being made to the quality and accountability of health leaders.
Yet more than this will be needed. Permanent change will not happen unless doctors and nurses live by their values and put patients first. In the past year I have met many doctors, nurses and leaders with a genuine commitment to making the NHS safe, effective and reflective of patients’ needs. Many feel free to speak up in a way that was not possible in the past.
A report with which I have been involved, published by the Nuffield Trust today, testifies to the willingness of hospital leaders to embrace a better way of doing things. Many interviewed for the report recognise the need for coherent national standards and openness, transparency and candour.
This is echoed by the CQC’s admission of past failings and the OBE for Helene Donnelly, the brave whistle-blowing nurse from Stafford. Victimisation of staff who raise honest concerns of the sort identified only last week by an employment tribunal in Devon cannot be tolerated. There is much to do in this area before staff feel safe.
The persistent belief that events at Stafford were unique and unlikely to occur elsewhere is dangerous and wrong. The Nuffield Trust report raises concerns about national organisations responsible for overseeing the NHS.
In particular there is a perception on the front line that regulators and commissioners revert too easily to old ways, applying pressure amounting to bullying to enforce targets and meet financial requirements. Hospitals trying to put patients first will soon be deterred if this is not stopped.
If, as I hear too often, the only conversation between senior NHS regulators and hospital boards is about finance and crude targets, the increased focus on quality will be forgotten. Reprimanding hospitals when they are honest about what they cannot do will not encourage openness. If regulators are behaving like this they must change; if the perception is wrong they need to change it.
I still hear of too many cases where legitimate complaints are met with prevarication and defensiveness. Changing this behaviour should not have to wait until the proposed duty of candour has been fully enacted. Openness should be part of the DNA of every hospital.
The Nuffield Trust report echoes widely-expressed fears that the new emphasis on quality cannot survive financial pressure. Safe and effective care, delivered with dignity and in open partnership with patients, should cost less, not more.
The NHS’s dreadful bill for litigation each year tells its own tale. Commissioning groups and national regulators must insist on fundamental standards just as firmly as they used to demand compliance with the four-hour A&E waiting time — and perhaps still do.
So, a good if slow start has been made, but much needs to be done. It is hard for anyone to relax until the constant stream of alarming stories seen daily by organisations such as the Patients Association fades away.
Robert Francis, QC, chaired the public inquiry into Mid Staffordshire NHS Trust. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.
This blog was first published in The Times.
Francis R (2014) ‘Openness should be in the DNA of every hospital’. Nuffield Trust comment, 6 February 2014. https://www.nuffieldtrust.org.uk/news-item/openness-should-be-in-the-dna-of-every-hospital