Never again? Roger Kline argues that Jeremy Hunt’s response to the Francis Report is inadequate.
Roger Kline, 8 April 2013
Robert Francis’s report on the biggest single scandal in NHS history stressed failings in regulation and inspection alongside failings of resources (not enough staff, wrong skill mix), failings of leadership (bullying culture to achieve financial and other targets at expense of patient care and safety), failings of trust (with patients and relatives, and among staff) and a complete absence of staff engagement (staff treated as cost not asset).
Jeremy Hunt’s response emphasises some aspects of regulation (new Chief inspector of hospitals, beefed up role for the Care Quality Commission (CQC), Ofsted-style ratings, a welcome duty of candour), although many hospital chief executives believe some of this framework will be ineffective. The response also commends some excellent existing examples of good practice, such as Schwartz rounds.
But its failure to address other key issues in the Francis Report has left many NHS patients, staff and managers sceptical about how the government will help ensure such scandals never happen again, especially given that there has been no change in the NHS leadership which presided over the toxic management culture revealed in evidence to the public inquiry.
The central challenge is to create a working environment in which staff feel valued and safe about sharing robust data and raising concerns, so that a learning safety culture is created. There is plenty of evidence that this is both crucial and works -- but also that we have some way to go.
The 2012 NHS staff survey revealed the shocking statistics that 24% of NHS staff say they were bullied in that year by managers and colleagues and 28% feared the consequences of raising concerns. Perhaps that is why the number of incident alerts fell by 100,000 at a time when, post Mid Staffs, one would expect them to rise.
Yet he government's response to Francis fails to address those issues. Although the response spends pages on whistleblowing, it fails even to mention bullying or to propose any measures to ensure that those who raise concerns are better protected when they do so.
Moreover, the 'reforms' that have just taken effect could make things worse. It turns out, for example, that some GP practices are actually forbidden from exercising their duty of candour by new Clinical Commissioning Group (CCG) constitutions.
Similarly, while Hunt promised that the patient would be "the first and foremost consideration of the system and everyone who works in it", he signed off on a revised NHS constitution -- now withdrawn -- that stated the NHS would “aspire” to put patients first, not actually do so.
While rejecting mandated minimum staffing levels and Francis’s call for regulation of healthcare assistants, Hunt calls for all trainee nurses to spend a “cost-neutral” year as healthcare assistants. That proposal is widely regarded either as unworkable or, worse, as suggesting that nurses were the major culprits in Mid Staffs. There are no equivalent year long plans for aspirant general managers, although some managers certainly had a compassion bypass in Mid Staffs.
Nor does Hunt explore how the £20 billion cuts and the chaos that the Health and Social Care Act has triggered will contribute to the required "culture change". The fragmentation and privatisation of services appear more likely to disrupt institutional memory and weaken incentives to put the patient first.
Six months ago I hazarded a guess at what Francis would recommend and the government’s response. I was downbeat. The Francis Report and the immense efforts of Julie Bailey and local Stafford relatives has forced a recalibration of the balance between finance and care, but the government’s response fails to meet the challenge.
After the Bristol Inquiry a decade ago we were assured 'never again'. This time, the best employers and many staff will undoubtedly do their best to improve safety and quality, and Don Berwick’s future safety recommendations may assist them. But it is taking optimism too far to conclude from the government's response to Francis that we will never again be told 'never again'.