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One year on from Francis: how much has changed in the NHS?

Brendan Martin and Roger Kline, 4 February 2014

Since the Francis Report was published a year ago, Public World has published our Duty of Care handbook and launched our Best Workplace initiative to improve staff involvement in the NHS. For further information and to discuss how we can help you with training and other support, please write to

On 6 February 2013 the Francis Report set out in immense detail how Mid Staffordshire NHS Trust, in its pursuit of Foundation status, systematically neglected and mistreated its patients and ignored or bullied those who challenged that descent into cruelty.

One year on, how much has changed in the National Health Service?

The “Francis effect” reversed the fall in nurse staffing levels, but only temporarily, and real terms funding cuts allied to low morale continue to make the problem worse.

The report vindicated the local Cure the NHS group, but then its leader, Julie Bailey, was subjected to a hate campaign, which included the desecration of her mother’s grave. The heroine of 12 months ago was forced out of Stafford, closed her business and now lives in a caravan park.

The previous rotten CQC regime was replaced by new leadership who appear determined  to shine a light on both good and bad care. But while its reports can show what needs to be done they do not produce the fundamental cultural change that is required.

NHS Trusts have become vicariously liable for how their staff treat whistleblowers, and “gagging clauses” have been banned. But whistleblowers continue to be victimised and the annual staff survey revealed the shocking extent of bullying.

Francis gave encouragement to staff and leaders for whom care standards always trumped targets. But their task has been made harder by a government whose priority has been to force through a radical reorganisation that, by forcing market forces into the NHS, will undermine precisely the co-operation and transparency required to sustain and replicate such practice.

The government has also continued to cut real terms funding at a time of rising demand and waited nearly a year before asking NICE to draw up guidance, which is yet to appear, about staffing and skills mix levels.

Building on Francis, the Berwick Review amounted to a manifesto for patient safety, and the Keogh Review provided CQC with a model of how to conduct inspections that are motivated by learning rather than blame.

However, the Cavendish Review was hampered by the government’s refusal to accept the Francis recommendation to regulate health care assistants, although the government has imposed top down regulation to enforce its marketisation agenda.

Both Francis and Berwick showed the need for staff to be properly valued, supported, listened to and engaged, and some Trusts have taken steps to improve staff wellbeing and patient safety. But in too many others leaders talk the talk without walking the walk.

Robert Francis QC himself has expressed his continuing commitment by becoming the president of the Patients Asslciation and joining the board of the new Point of Care Foundation, which has pioneered the introduction of Schwartz Rounds to improve the emotional and psychological support available to NHS staff.

The Foundation also published a launch report, Staff Care, which draws attention to the importance of improving staff engagement through such initiatives as Public World’s Best Workplace methodology, which we are introducing in the NHS following a successful workshop with NHS Employers.

Public World also produced our Duty of Care handbook, which provides practical guidance to healthcare professionals about how to assert their right to put patients first, even when they come under pressure to do otherwise. This has been received enthusiastically in several NHS trusts and a special new edition has been commissioned by Unite the Union and will be published imminently.

In short, many NHS leaders, staff, union representatives and supporters are working to bring about the kind of culture change demanded by the millions of words, thousands of pages and hundreds of recommendations of the Francis Report.

But if those initiatives are to become mainstream rather than pockets of good practice we need a government and NHS leaders committed to what we identified a year ago as, and still believe to be, the paragraph of the Francis Report that best sums up its key message.

Having noted the cultural degeneration experienced in Mid Staffs, Francis states that while the characteristics revealed there were not present throughout the NHS all the time, "their existence anywhere means that there is an insufficiently shared positive culture".

He added (paragraph 1.118): "To change that, there needs to be a relentless focus on the patient’s interests and the obligation to keep patients safe and protected from substandard care.

"This means that the patient must be first in everything that is done: there must be no tolerance of substandard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations."

Public World is passionate in its commitment to work positively and creatively in the NHS to support the efforts of its leaders, staff and unions to make that vision a reality, everywhere. To discuss how we can help you, please contact us at

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