Transcript Document

The Francis report and its
aftermath
Conor Davidson
Compassion
Candour
Culture
Training
Leadership
Assurance
2001
First Annual Dr Foster guide shows
that Stafford Hospital had a higher
than expected HSMR at 108.
2006
Reports in the local press that hospital is in a
‘squalid state’ (after visit by Terence Deighton)
2007
• June
– Monitor begins the review of the Stafford Trust
application for foundation status.
• July
– Dr Foster Unit sends Trust a series of mortality alerts.
• Oct
– First Royal College of Surgeons Report.
2008
• Jan
– 'Cure the NHS' campaign group set up
• Feb
– Trust granted foundation status
• Mar
– HCC launches investigation
Video
2009
• Mar
– Healthcare Commission report published
– Chair and Chief Exec resign
• July
CHAOS KILLS UP TO 1200 IN
ONE HOSPITAL
– Second Royal College of Surgeons report
– Public enquiry (Francis I) announced by new sec of
state Andy Burnham
2010
• Feb
– Francis I published
• May
– Coalition Government take power
• June
– Andrew Lansley commissions Francis II
"an atmosphere of fear of adverse repercussions"
"forceful style of management"
"pressure to meet targets"
"systemic failure of the provision of good care"
"too few staff, or staff not sufficiently qualified to cope"
"incontinent patients left in degrading conditions"
"injury and loss of dignity, often in the final days of their lives"
"delayed diagnosis"
"constant strain of financial difficulties"
"isolation from the wider NHS community"
"lacked effective clinical governance"
2013
• February
– Francis report published
• July
– Keogh report investigating 14 outlier trusts published
• August
– Berwick NHS safety review published
• October
– Ann Clwyd review of NHS complaints system published
• November
– official government response to Francis report
Compassion
• At Stafford:
–
–
–
–
–
–
–
Soiled patients unattended
Call bells not answered
Patients being left without food and water
Extremely poor hygiene
Medication not administered properly
Lack of adequate heating
Failure to notice or respond to deteriorating
conditions
– Failure to listen to, take seriously and respond to
concerns of relatives
Compassion
Recommendations:
Core values and fundamental standards**
Aptitude test*
Nurse training include 'at least 3 months' hands on
care**
Named nurses for patients**
Regulation of Healthcare Support Workers
Consider creating role of registered older people's
nurse*
NICE to recommend staffing levels** (but note
Keogh on reported vs actual staffing levels)
Leadership
At Stafford:
Financial problems since 2003/04
Bullying management culture
Board focused on achieving foundation trust status
Ill thought-through staff cuts and service
reconfigurations
Dysfunctional consultant body
Leadership
Recommendations:
'Fit & Proper' person test for directors**
Leadership college*
System of accreditation/training for leadership
posts*
DoH should do impact assessments before any
structural change of the healthcare system*
Candour
• Openness – enabling concerns and complaints to
be raised freely without fear and questions asked
to be answered.
• Transparency – allowing information about the
truth about performance and outcomes to be
shared with staff, patients, the public and
regulators.
• Candour – any patient harmed by the provision of
a healthcare service is informed of the fact and
an appropriate remedy offered, regardless of
whether a complaint has been made or a question asked
about it.
Candour
• At Mid Staffs:
Disregarded criticism
Ineffectual complaints system
Isolated from wider NHS
No support for whistleblowers
High HSMR blamed on coding error
Falsified records in A&E
Candour
Recommendations:
More effective NHS complaints system**
Statutory 'duty of candour' - to patients, public and
regulators*
Gagging clauses should be banned**
Regulators should share information**
Common information practices**
Real time effective accessible data**
Assurance
At Mid Staffs:
Poorly developed audit/clinical governance systems
Board unaware of situation on the ground
Ignoring indicators of poor performance
Failure of regulatory system
“The current NHS regulatory system is
bewildering in its complexity”
-Berwick report
Asssurance
Recommendations:
Fundamental/enhanced standards*
Clear metrics on quality**
(Note Keogh on mortality ratios)
Fundamental standards should be rigorously enforced
and to cause death or serious harm to a patient by
noncompliance should be criminal offence**
Single regulator
Beefed up commissioners*
Note role of medical training in assurance
Culture
At Stafford:
Early warning signs - shabby & dirty environment,
unsmiling staff who were distracted by mobile phones,
didn't answer buzzers promptly, didn't pick up litter
Isolated 'timewarp'
Toleration of mediocrity
'Keep your head down'
Bullying
Isolated
'Systems business' put over patients business
Culture
Recommendations
All of them!
Focus on 'culture of caring'
'Cultural barometer'
Vague points about values, teamwork, post discharge care
Frustration at political interference in NHS
Schwarz rounds
Can cultural change be achieved through top down
recommendations?
“In the end, culture will trump rules, standards and control strategies every
single time, and achieving a vastly safer NHS will depend far more on major
cultural change than on a new regulatory regime.”
-Berwick report
Training
• Junior doctors in Stafford A&E and MAU (‘Beirut’)
silenced
• Lack of value and support being given to frontline
clinicians, particularly junior nurses and doctors…’their
energy must be tapped not sapped’
• Five of Keogh organisations having training monitored
by GMC
• Deanery to visit local providers & report back to GMC
• Medical students & trainees to be surveyed
• All overseas doctors (inc EU nationals) need English
language proficiency
The aftermath…
Run out of town
Placing the quality of patient care, especially patient
safety, above all other aims.
Engaging, empowering, and hearing patients and carers
throughout the entire system and at all times.
Fostering whole-heartedly the growth and development
of all staff, including their ability and support to improve
the processes in which they work.
Embracing transparency unequivocally and everywhere,
in the service of accountability, trust, and the growth of
knowledge.
– Berwick report