Robert Francis QC talks to the Nuffield Trust about the impact of the Francis Inquiry

Robert Francis QC spoke at a Nuffield Trust event marking the anniversary of the Francis Inquiry Report. Read his statement.

Press release

Published: 06/02/2014

On 6 February 2014 Robert Francis QC delivered this speech at the Nuffield Trust event: The Francis Inquiry: the impact one year on.

Check against delivery

Four years ago, in February 2010 I published a report laying bare the shocking care that had been provided to far too many patients in Stafford Hospital.

I heard of an elderly patient left naked in public view covered in faeces; of another who died because she not given the insulin which clinical staff knew she needed; of wards in which elderly patients were not helped with their food and drink; of a dysfunctional surgical department, of an A&E where waiting times were fabricated; staff who raised genuine concerns were not listened to or respected, and where patients and their families were not listened to.

This time last year I published the report of the public inquiry into the behaviour of the system in relation to the issues raised in Stafford. It painted a worrying picture.

I found that a weak leadership had given priority to cost control, corporate governance and promotion of a reassuring image ahead of patients and their safety. They failed to listen to patients or staff and were preoccupied with targets while missing their point. Staff gave up raising concerns for their patients and kept their heads down.

In general, I have been very encouraged by the response to my report Robert Francis QC, at the Nuffield Trust event marking the anniversary of the Francis Report

In the wider NHS good news about performance was not evaluated critically, and bad news pointing to potentially serious issues was ignored or discounted. Corporate memory and continuity were lost through reorganisations and lack of staff retention.

Accountability was deficient or absent in many managerial positions, and support for leadership at all levels was inadequate. Important information about patient safety was not shared properly. The vital connection between the hierarchy and those providing the service was often tenuous.

In the light of all this I made 290 recommendations to address these systemic failings to put patients at the heart of the service. I identified six themes:

  • common patient-centred values throughout the system;
  • openness transparency about how the service is performing and candour about harm to patients;
  • compassionate, caring, committed nursing;
  • strong patient-centred health care leadership;
  • accurate, useful and relevant information allowing all to understand how safe, effective and good the service is.

A long time has passed since the shocking events in Stafford first came to public attention. Since then the need for substantial cultural change has been generally accepted. The challenge has been to find ways of putting that into practice.

I recommended that progress in implementing these changes should be reviewed and reported on regularly by all organisations in the service. I welcomed the opportunity to be associated with the production of this Nuffield Trust report, for which I have written a foreword, and believe it is a helpful part of the process of review I envisaged.

Sally Williams has already this morning outlined the findings from the Nuffield Trust’s research study. I intend to pick out some of the things that resonated with me but will leave the authors to speak for the research in detail.

In general, I have been very encouraged by the response to my report. The Government has accepted in spirit the vast majority of my recommendations and has set about implementing them.

The Secretary of State and other leaders have expressed a determination to do whatever can be done to ensure that light is shone on the darker corners of our health service. They have made it clear that lapses in the most fundamental standards of care should not be tolerated.

They agree that all staff must be supported to live by the professional values and obligations that the vast majority want to fulfil. That determination has manifested itself in, among other developments, the Keogh review and the new professionalised inspection techniques deployed there, the Secretary of State’s recent promotion of named doctors and nurses for individual patients, the development and publication of individual performance measures for an increasing range of specialities, the Care Quality Commission’s (CQC) commitment to openness in its own work, and the development of high quality training for NHS leaders.

In the end the success of the system in implementing a patient-centred open culture will depend not solely on ministerial pronouncements, inspections, ratings, training schemes, improved governance, and so on.

Change will not happen without the determination of health care professionals to put their values into practice, and to individually and collectively put the patient first in all that they do. This involves commitment, courage, and collective action in the interests of their patients. It involves listening to those patients, and to colleagues, and learning from them better and safer ways of providing the service.

There is much in this Nuffield Trust report which testifies to the willingness of most in the health service to embrace a better way of doing things, and to the beginnings of the action that is needed in relation to all the themes I have mentioned.

It was encouraging to see that many did not wait for the public inquiry report to start doing what the first report showed was needed. It appears that many have grasped the nettle of developing their own version of fundamental standards without waiting for the outcome of the CQC consultation: this is absolutely the right thing to do.

Although the report is based on a relatively small sample and we need to avoid drawing overemphatic conclusions, it does however support the need for coherent national standards and a reduction in duplication of work for different regulators, both of which remain works in progress.

Trust leaderships have to make sure that they implement what their own staff consider works for their own patients. The need to develop methods of measuring performance against standards is also well recognised.

Equally welcome is the recognition among many respondents of the importance of openness transparency and candour, in particular through improvements in complaints handling and in listening to staff.

I believe that this recognition has been reflected at national level among other things, by the ready ministerial acceptance that change and improvement are needed, by the admissions made by CQC as to its past failings, and, at a personal level in the OBE awarded to Helene Donnelly, the brave whistle-blowing nurse from Stafford, in the New Year.

It is important that no tolerance is afforded to oppressive managerial behaviour of the sort identified only last week by an employment tribunal in the South West, which victimises staff who raise honestly held concerns. Every such case is hugely damaging to the confidence of other staff who are contemplating raising concerns. It is clear that there is much to do in this area.

Finally, the need to improve the information available to all about how the service is performing has been taken on board. Nothing will promote improvement more quickly than reliable, relevant and accessible information on how services are performing, not by reference to remote targets, but by looking at the success of treatment and care from the patient’s perspective.

Unfortunately the picture, although encouraging, is not entirely reassuring. I sense there remain those who reassure themselves that a Stafford could not happen on their patch. I believe such a belief is seriously mistaken, even in the many parts of the health service where excellent care is provided.

It must be remembered that much good care was provided in Stafford as well. Unhappily the Keogh review confirmed that very worrying lapses were occurring elsewhere. Drawing attention to unacceptable care is not an attack on those who strive to provide excellence.

It is often those who are doing well who have it in their power to identify what is wrong and root it out. It is the part of the essence of medical professionalism to protect patients from poor care and to support those who shine a light on what is unacceptable.

The response described by some individuals in this report also causes some concern about the behaviour of national bodies − or at least the perception of the way they do things when viewed from the front line.

In particular there is a fear that commissioners and regulators easily revert to old ways of applying pressure amounting to bullying in order to enforce targets and financial requirements. The report shows the presumably unintended effect that contact from regulators can have, if the subject is invariably about meeting targets. As one respondent told the researchers “it feels like it did five or six years ago”.

And while there might have been an increased focus on quality, if at senior level the only conversation between Monitor and trust boards is about finance and performance targets the importance of the standards provided to patients will get lost again.

Monitor and other bodies need not only to embrace and promote the quality agenda, as it says it is doing, but ensure that trusts believe that safety quality and effectiveness are given their proper importance.

Reprimanding a trust for honestly reporting that they could not provide the required quality as well as meet the financial target, as was one respondent’s experience of a strategic health authority (SHA), is not the way to encourage openness, and patient-centred care. As one clinician said:

“If management behaviour is punitive, shouty and target driven, that filters down.”

If such a pattern reasserts itself, patients will suffer. Trusts trying to live by the new way of doing things, putting patients first, will soon be deterred if the behaviour of commissioners and national regulators is not seen to change in the same way.

Those in senior national positions need to remember the unintended consequences of pressurising providers to meet centrally imposed access targets and requirements to seek foundation trust status.

Some respondents have inevitably drawn attention to the perceived tension between a focus on quality and financial constraint. I believe that such concerns are understandable but misdirected.

Financial savings do not necessarily mean that safety, dignity and effectiveness are compromised. Indeed it is likely that poor care wastes money rather than saves it. We need to remember that the awful things that happened in Stafford should have no place in any health service.

An organisation which is commissioned to treat elderly vulnerable patients cannot excuse failures as gross as those I have described by want of funds. If a provider truly has not got the funds to provide a better service than that it should decline to offer the service at all.

To pretend an acceptable level of service can be delivered when it is not possible to do so, is to deceive patients and the public. If sufficient staff are not provided to care for patients in an acceptable fashion then all professionals involved need to make their voice on behalf of patients heard loud and clear.

No-one has ever said that changing a system as important and complicated as the NHS would be easy. It is clear that many hard working staff at all levels of the system have showed determination in achieving this.

As they will recognise there is much still to do, and keep doing, to ensure that all patients get what are entitled to, namely care and treatment which is safe, effective, and of good quality, delivered by well supported and valued staff.

Their task can be made easier if the regulators and others focus on quality requirements as much as they do on financial ones. If all continue to be open and honest about the things that have not worked as well as the many successes, and if patients are brought into the centre of all that is done for them, then those who suffered by badly in Stafford and elsewhere can begin to feel that some good has come out of what happened to them.

In short, the time for discussion of what needs to be done has surely passed.

It is now vital to get on with making sure real change happens, and happens now.

Notes to editors

Robert Francis QC spoke at the event: The Francis Inquiry: the impact one year on (6 February 2014). View a storify of reactions on Twitter at the event.

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