"First, do no harm": are hospitals failing their patients?

"...the story it tells is first and foremost of appalling suffering of many patients."

Francis Report, February 2013

"You can't legislate to make people compassionate"

A senior government source, quoted in the Daily Telegraph, 6 February 2013

If the NHS is the national religion, then today a lot of people will have had their faith shaken.

This morning Robert Francis QC produced a report on the "serious failings" that resulted in up to 1200 deaths at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. This public inquiry, originally commissioned in June 2010, sought to establish how "a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies" did not succeed in protecting local patients when there were clear warning signs that many of them were receiving substandard care.

The tone of Mr Francis' report is one of disbelief and quiet outrage. Unusually, the Prime Minister made a statement to the House of Commons in response to his findings.

What happened to prompt the public inquiry?

There have already been a number of separate reports on the dire situation that developed at Mid Staffs. Initial concerns about higher than average mortality rates resulted in an investigation by the Healthcare Commission (HCC). This was followed by two reviews commissioned by the Department for Health.

Then, in early 2010, Mr Francis produced an initial report on how standards of patient care had deteriorated at the Mid Staffordshire hospitals. It included shocking evidence of patients lying in soiled sheets and staff neglecting their basic needs.

The latest inquiry focuses on the faulty system of regulation that allowed this crisis to develop and flourish, apparently undetected.  

How could this have happened?

The report makes clear that while the board of the Mid Staffs Foundation Trust must accept a share of the blame, "the system as a whole failed in its most essential duty".

There was already cause for concern when in 2007 the Board decided to apply for Foundation Trust status (in other words, to make a bid for financial independence). In 2007 an inpatient survey identified several areas where the Trust was among the worst performing 20% in the country. In the same year, the surgical department of Mid Staffordshire hospital had been described as "dysfunctional" by the Royal College of Surgeons.

But, as Mr Francis notes, the board failed to consider that the cost-cutting involved in earning Foundation Trust status might be to the detriment of patient care:

"Savings in staff costs were being made in an organisation which was already identified as having serious problems in delivering a service of adequate quality, and complying with minimum standards. Yet no thought seems to have been given in any part of the system aware of the proposals to the potential impact on patient safety and quality."

Mr Francis points out that although any hospital seeking Foundation Trust status is required to undergo a rigorous assessment process, none of the deficiencies at Mid Staffs were uncovered. While both the Conservative and Labour parties have backed the idea of hospitals becoming autonomous entities, Mr Francis suggests that the Mid Staffs oversight calls into question the effectiveness of the whole regulatory system.

As it stands, the Mid Staffs Foundation Trust application (like any other hospital's) was assessed by the Healthcare Commission and Monitor - separate organisations with different areas of expertise (clinical and financial, respectively). What's more, seeing as a hospital is asked to measure its own strengths or weaknesses in a number of areas, the management might be less likely to identify signs of failure if this will jeopardise its application.

"With the benefit of hindsight..." - How can we stop it from happening again?

The report lists 290 recommendations (for an overview, see Chapter 2 of the Executive Summary).

Mr Francis is clear that "Effective accountability to the public demands a simpler regime of regulation." Firstly, he says, there's a need for a charter of care standards. He also proposes that the Care Quality Commission (CQC), in addition to its own duties, assumes Monitor's role (that of assessing the governance of NHS Foundation Trusts).

He suggests that it should be a criminal offence for any health professional to make an "untruthful statement" to a regulator, while whistleblowers ought to be protected by statute.

He argues that there's no need for "further "top-down" pronouncements" but instead the "engagement of every single person serving patients in contributing to a safer, committed and compassionate caring service".

Practical hands-on training should be a pre-requisite for people wanting to enter the nursing profession, and healthcare support workers should be subject to a system of registration. 

Mr Francis does not say that the staff at Mid Staffs Foundation Trust were particularly sadistic or negligent. But of course, whether someone is in the caring professions or not, most people want a career. And in any job, if you admit to a mistake or if you fail to meet a target, you're less likely to be promoted. Mr Francis posits that a culture of "openness, transparency and candour" would encourage staff and different components of the health service to cooperate in improving patient care.

What's been the reaction to the report?

In his response to the Francis report, David Cameron said that the Government intends to make it possible for a hospital's board to be dismissed when there are failures of care. At the moment, a board is only accountable for any financial failure. He also suggested that nurses' pay might be linked to the quality of care they provide, rather than the duration of their employment.

At the same time, he announced the creation of a new post at the Care Quality Commission. The Chief Inspector of Hospitals will investigate standards of cleanliness and safety, as well as assessing the quality of care on offer.  

In his first report, Mr Francis proclaimed, "If there is one lesson to be learnt, I suggest it is that people must always come before numbers." Perhaps, Mr Francis is here making a reference to cost concerns. However, more generally, numbers are how we count people - how we measure their experience, how we identify where standards have lapsed, and how we make the case for improvements. Perhaps the challenge is rather how we might ensure that numbers better represent people.