Transcript Document

Dr Peter Miller
Executive Director
Clinical Governance and Medical Affairs
Dean Howells
Executive Director
Nursing, Quality and Patient Experience
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Francis Report
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Events of 2005-2009
Considers why the
serious problems at
the Trust were not
identified and acted on
sooner
Identifies important
lessons for the NHS
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What did patients say in 2010
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Privacy
Dignity
Staff attitude
Nutrition and hydration
Pressure ulcer care
Toileting needs
Cleanliness
Communication
Safety
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What were the warning signs?
Loss of star rating
3 external peer reviews critical
Healthcare Commission review into children's
services
Internal Audit reviews into governance
Poor staff and patient surveys
Royal College of Surgeons report FT application
led to financial recovery plan with staff cuts, no
scrutiny of quality impact
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Analysis of evidence
The inquiry report examines what each
organisation knew and what, if any, action was
taken to address these concerns
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Trust Board
The Trust Board prioritised finance and its FT
application, over quality of patient care
Failed to engage clinicians
No culture of listening to patients
Lack of focus on clinical standards
Inadequate governance and risk assessment
Poor clinical leadership
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The voice of the local community
Not heard, multiple reorganisation
Community health councils
Patient and public involvement forums
LINks
Overview and Scrutiny Committee
No effective voice
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Primary Care Trusts
Under a duty to monitor and improve quality of
services
Focused on financial transactions and a handful
of targets
Multiple reorganisations
Recognised issues. However, difficulty in using
contractual solutions to drive change
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Strategic Health Authorities
Significant reorganisation impacting on corporate
memory
Lack of clarity about who was responsible for
monitoring quality
Poor available metrics
Undue focus on financial recovery and targets
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Monitor
Undertook comprehensive assessment in 2007/8
Failed to identify deficiencies
Lack of communication with HCC
Resulted in false confidence to Board - others
stood back
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Healthcare Commission
Reliance on self assessment
Lack of information to challenge self assessment
Their detailed review began the process of
uncovering the problems
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Care Quality Commission
Lack of clarity on fundamental standards
Patient information and feedback are not
priorities as a means of obtaining information
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Professional Regulation
Nothing was brought to the regulators’ attention
Trainees had concerns but not heard.
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Why were things not discovered
sooner?
Organisation lacked insight and awareness,
defensive
Lack of clarity of role in external agencies
No effective communication between external
agencies
Constant reorganisations
Measurement focused on process targets, not
outcomes
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Dean Howells
Executive Director Nursing,
Quality & Patient Experience
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A structure of fundamental standards
and measures of compliance
 NHS Constitution and values:
 Strengthen NHS Constitution to place patients first as an ‘overriding
value’ and to articulate fundamental standards of staff behaviour;
 Development of fundamental standards – of behaviour, safety and
quality:
 List of clear, fundamental quality and safety standards, which any
patient is entitled to expect and to permit any hospital service to
continue
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 NICE should produce standard procedures and guidance to enable
organisations and individuals to comply with these fundamental
standards. They should work with professional and patient
organisations to do so, and cover clinical outcomes as well
as staff mix and cultural outcomes
 ‘Enhanced standards’ should be developed and made available to
commissioners to raise standards. Clear focus on the role of
commissioners in driving standards;
 Non-compliance should not be tolerated and any organisation not able
to consistently comply should be prevented from continuing a service;
 Causing death or serious harm to a patient by non-compliance without
reasonable excuse of the fundamental standards should be a criminal
offence.
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Openness, transparency and candour
through the system underpinned by statute
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A statutory duty to be truthful to patients where harm has or may
have been caused;
Staff to be obliged by statute to make their employers aware of
incidents in which harm has been or may have been caused to a
patient:
Trusts have to be open and honest in their quality accounts which
will be consistent, publicly available. Quality and risk profiles
should also be made public:
The deliberate obstruction of the performance of these duties and
the deliberate deception of patients and the public should be a
criminal offence;
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It should be a criminal offence for the directors of Trusts to give
deliberately misleading information to the public and the
regulators;
Proposals for strengthening support for governors, and for
strengthening the role of governors and NEDS including their
accountability to the public;
Complaints handling must be improved nationally and locally;
There should be a consistent structure for Healthwatch across the
country;
Each provider board should have a member responsible for
information;
The CQC should be responsible for policing these obligations
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Improved support for compassionate,
caring and committed nursing
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Nurses should be assessed for their aptitude to deliver and lead proper
care, and their ability to commit themselves to the welfare of patients
Training standards need to be created to ensure that qualified nurses are
competent to deliver compassionate care to a consistent standard;
Nurses need a stronger voice with suggestions NMC strengthens its role
Healthcare workers should be regulated by a registration scheme, with a
uniform description of their role
Patients should be allocated a key nurse for each shift. Ward leaders
should not be office bound
Particular attention should be given to care for the elderly (potential of
new part of NMC reg)
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CODE OF CONDUCT Clinical Leads bands 2-4
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Stronger healthcare leadership
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An NHS leadership college to offer potential and
current leaders the chance to share in a common
form of training to exemplify and implement a
common culture, code of ethics and conduct;
It should be possible to disqualify those guilty of
serious breaches of the code of conduct or
otherwise found unfit from eligibility for leadership
posts;
A registration scheme and a requirement need to be
established that only fit and proper persons are
eligible to be directors of NHS organisations;
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Requirements on FTs to provide adequate training
for directors;
Strengthened role for training organisations in
providing safety information, for instance
recommended skill mix and staff ratios;
Professional regulators to play a tougher role in
relation to protecting patients and the public;
Health Education England should have a medical
director and a lay person on its board. LETBs
should have a post of medically qualified post
graduate dean
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Accurate, useful and relevant information
 Information is the lifeblood of an open transparent and candid
culture
 All professionals, individually and collectively, should be obliged to
take part in the development, use and publication of more
sophisticated measurements of the effectiveness of what they do,
and of their compliance with fundamental standards
 Patients, the public, employers, commissioners and regulators
need access to accurate, comparable and timely information
 Improvements are needed in the core information systems for the
collection of data about patients, both to support their individual
treatment and the accurate collation of information for statistical
purposes
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Recommendations
290 recommendations grouped into 21 sections
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Accountability for implementation (2)
Putting the patient first (6)
Fundamental standards of behaviour (4)
A common culture (6)
Responsibility for and effectiveness of healthcare
standards (40)
• Responsibility for and effectiveness of regulating
healthcare systems (Monitor) (27)
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• Responsibility for and effectiveness of regulating
healthcare systems (Health & Safety Executive) (4)
• Enhancement of the role of supportive agencies
(NHSLA, NPSA, HPA) (18)
• Effective complaints handling (14)
• Commissioning for standards (16)
• Performance management (6)
• Patient, public and local scrutiny (7)
• Medical training and education (21)
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Openness, transparency and candour (12)
Nursing (29)
Leadership (8)
Professional regulation of fitness to practise (14)
Caring for the elderly (8)
Information (29)
Coroners and inquests (13)
Department of Health leadership (5)
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It is recommended that …
 All commissioning, service provision, regulatory and
ancillary organisations in healthcare should consider the
findings and recommendations of this report and decide
how to apply them to their own work
 Each such organisation should announce its decision
on the extent to which it accepts the recommendations
and what it intends to do
 Publish once a year information regarding its progress
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Table reflections
Please take 5 minutes to reflect on the report
and its implications
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My personal reflections
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The NHS constitution
How do we reinforce the values of the NHS?
Clinical leadership - fundamental standards
How do we listen to service users?
Self regulation
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“The failure of the system shown in this report shows
that a fundamental culture change is needed. This
does not require a root and branch reorganisation – the
system has had many of those.
“I hope this report can contribute to that end and put
patients where they are entitled to be – the first and
foremost consideration of the system and everyone who
works in it.”
Robert Francis, QC
2013
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