After Francis: making a difference - Health Committee Contents

1  Introduction

The Francis Report and its significance

1. The failings at Stafford General Hospital first made public in the report of the Healthcare Commission in March 2009 have cast a shadow over the reputation of the NHS for safe, high-quality patient care. So significant were the failings in the Trust, and in the broader healthcare management system supporting it, which were revealed in subsequent inquiries that in February 2013 the Prime Minister made a public apology on the floor of the House of Commons in response to the publication of the report of the Public Inquiry into the Mid Staffordshire NHS Foundation Trust.[2]

2. The facts of the significant failure at Stafford, as initially audited by the Healthcare Commission and given prominence by the campaign group Cure the NHS, have underlain the debate over safety and quality in the NHS for several years. The findings of the Healthcare Commission's investigation and of the reviews into the Mid Staffordshire NHS Foundation Trust undertaken for the Department of Health by Professor George Alberti and Dr David Colin-Thomé were available to the predecessor Committee when it inquired into patient safety in 2009.[3] Since then, two inquiries, both chaired by Robert Francis QC, have examined the particular failings at Stafford Hospital and the more general inadequacies in the healthcare system which allowed the poor care at Stafford to persist for so long. The evidence taken in the course of both Francis inquiries—particularly the shocking experiences of poor care related by patients and relatives—informed two substantial and important reports which have provided compelling analyses of what went so badly wrong in a system supposedly geared to promoting excellence in healthcare.

3. In the report of the second inquiry into Mid Staffordshire NHS Foundation Trust, a public inquiry held under the provisions of the Inquiries Act 2005, Robert Francis has anatomised the operation of the NHS system and the interrelationships of the various bodies—Trust Board, regional health authority, Government department, regulators and others—entrusted with the responsibility of operating a safe and high quality healthcare system.[4] In doing so he has indicated key components of a prevailing culture at Mid Staffs which he characterises as 'doing the system's business': by definition, this was a culture which tended to prioritise the smooth operation of the healthcare system above the safe and effective care of patients.

4. The importance of Robert Francis' report lies not only in its meticulous analysis of the system, identifying areas where misplaced assumptions, perverse incentives and the pursuit of natural human instincts inhibited the ability of the system to deliver high quality care, but also in its description of a culture where the most shocking and obvious deficiencies in care were apparently allowed to persist unchecked, with consequences for patients and relatives which were completely unacceptable. It is vital that the pervasiveness of this culture in many parts of the health and care system is recognised.

5. The Francis report commands such attention, over four years after the initial Healthcare Commission report, because it describes a system where such lapses from basic standards appear still to be possible, and because there are so few guarantees that elements of the failings at Mid Staffs could not be repeated in other hospitals. Robert Francis has described a healthcare system established for the public benefit and funded from public funds which now risks an undermining of public confidence in its guarantees of safety and quality.

6. The Committee is in no doubt as to the importance of the failures at Mid Staffs. It is vital to the interests of patients that the lessons from these failures are learned and acted upon, so that all patients can have confidence in the quality of care in the NHS. Without in any way detracting from the importance of this process, the Committee also believes that it is important to recognise that the experience of those patients at Mid Staffs who experienced poor care is not the day-to-day experience of millions of NHS patients treated each year by caring, experienced and committed staff. The purpose of highlighting the key lessons of the Francis Inquiry is not to undermine the NHS but to improve it.

The Francis recommendations and subsequent reviews and responses

7. Robert Francis' report makes 290 recommendations for change in the health and care system, though, in truth, all can be summed up in one single recommendation—that the culture of the NHS must change in order for the safety and quality of the service, and the public's confidence in it, to improve. Robert Francis indicated that he was anxious that the report and its recommendations should stimulate real and lasting change. The Committee is similarly concerned that the inquiry process, harrowing for the patients and relatives involved and traumatic for conscientious public servants in the NHS, should lead to a lasting and positive change in culture.

8. The Prime Minister announced a number of headline measures in response to the Francis Report on the day of publication, and the Government subsequently issued what the Secretary of State described as a substantive response on 23 April 2013, which set out a more detailed response to certain areas in which Francis made recommendations.[5] The Committee has taken account in this report the proposals in the initial Government response, including the proposals for legislation in the Care Bill [Lords] and the proposals for a new inspection framework published by the Care Quality Commission. A further Government response, containing a detailed response to each Francis recommendation, is expected later in the autumn of 2013. This response is to be informed by the findings of four reviews commissioned by the Government to examine areas of concern to Francis. Three of these were issued after the Committee had concluded taking evidence in its inquiry and a fourth has yet to be issued:

·  A review of the training and support of healthcare and care assistants, undertaken by Camilla Cavendish: the report of this review was published on 10 July 2013.[6]

·  A review of safety practices in the 14 NHS Trusts and Foundation Trusts which have been outliers for the last two years on either or both of the recognised mortality indicators,[7] undertaken by the NHS Medical Director, Professor Sir Bruce Keogh: the report of this review was published on 16 July 2013 and the Secretary of State made a statement to the House on its findings the same day.[8]

·  A patient safety review undertaken by a National Advisory Group on the Safety of Patients in England, chaired by Professor Don Berwick: the report of this review was published on 6 August 2013.[9]

·  A review of NHS complaints handling, undertaken by Rt Hon Ann Clwyd MP and Professor Tricia Hart: this review has yet to report.

9. In addition, the report of an independent review of the Liverpool Care Pathway commissioned by the Minister of State, Department of Health in January 2013 and undertaken by a team led by Baroness Neuberger was published on 15 July 2013. [10] While this review was not commissioned in direct response to the findings of the second public inquiry into Mid Staffs, it followed a number of stories about complaints of poor and insensitive care and communication which "appeared to have much in common" with the complaints which prompted the Mid Staffs inquiries.[11] In response to the review the Minister of State for Care Services, Norman Lamb MP, announced on the same date that the Government's intention is for the Liverpool Care Pathway to be phased out "over the next six to 12 months", to be replaced by "an individual approach to end of life care for each patient".[12]

10. This report gives the Committee's view on the issues raised by Robert Francis' report and the Government's initial response, on which it has taken evidence, together with relevant issues thus far raised in the subsequent responses and reviews. The Committee plans to keep the Government's response to the full set of Francis recommendations under review in the course of its ongoing programme of scrutiny.

The Committee's inquiry

11. Robert Francis published the report of the public inquiry on 6 February 2013 and gave evidence to the Committee on its findings on 12 February 2013. The report consisted of three volumes, plus an executive summary, and contained 290 recommendations. The Government published its initial response to the report on 23 March 2013 and the Secretary of State made an oral statement to the House on the report the same day. Subsequently the Secretary of State appeared before the Committee on 23 April 2013 to discuss the report and the Government's response to its recommendations made to date. The Committee also took oral evidence from Sir David Nicholson KCB CBE, Professor Sir Bruce Keogh KBE and Liz Redfern CBE, representing the NHS Commissioning Board (now known as NHS England).

12. Following allegations made shortly after the report's publication that a Trust was seeking to prevent a former employee from discussing in public issues relating to patient safety at that Trust, the Committee invited Mr Gary Walker and Mr David Bowles, respectively the former Chief Executive and Chairman of United Lincolnshire Hospitals NHS Trust, to give evidence on the actions of NHS bodies which they considered had been designed to prevent Mr Walker, or had had the effect of preventing Mr Walker, from discussing in public issues of patient safety.

13. The relevant sections of this report are intended to inform debate on the clauses in Part 2 of the Care Bill [Lords] which make provision to change the structure of quality and safety regulation for care providers. The Committee recommends that the Government should provide a response to the Committee's report in good time for it to be taken into account in the Second Reading debate in the Commons on the Care Bill [Lords].

Parliamentary oversight of professional regulation

14. Robert Francis recommended that the Committee, through its arrangements for regular accountability hearings with professional and system regulators and otherwise, should monitor the implementation of his recommendations and the development of the cultural change in the NHS which he considers vital. The Committee agrees with Robert Francis' recommendation for its role in monitoring implementation of his recommendations. The Committee therefore proposes to enhance its scrutiny of regulation of healthcare professionals by taking public evidence each year from the Professional Standards Authority for Health and Social Care (the PSA, formerly the Council for Healthcare Regulatory Excellence) on the regulatory environment and the performance of each professional regulator, based on the PSA's own annual report. The Committee held an initial evidence session on 9 July with representatives of the PSA to examine its annual report and performance review for 2012-13.[13]

15. The Committee plans to draw on the views expressed by the PSA in its reports and in these sessions in preparing for its regular accountability hearings with the General Medical Council and the Nursing and Midwifery Council. It will also examine the case for inviting other professional regulators under the PSA's remit to appear before it from time to time, in the light of the views expressed about their performance by the PSA.

16. The Francis Report demonstrated that failure of professional responsibility was a key factor which contributed to failures of care at the Mid Staffordshire NHS Trust. The Committee has also consistently emphasised the importance of an open and accountable professional culture in its own reports during this Parliament. It welcomes Robert Francis' recommendation that there should be enhanced parliamentary oversight of the quality of professional regulation, and it intends to develop its relationship with the PSA to make this oversight as effective as possible.

2   HC Deb, 6 February 2013, columns 279-83 Back

3   Sixth Report of the Health Committee, Session 2008-09, Patient Safety, HC (2008-09) 151 Back

4   Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, HC (2012-13) 898 I-III (report) and HC (2012-13) 947 (executive summary) (hence Francis ReportBack

5   Patients First and Foremost: The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry, Cm 8576, March 2013 Back

6   The Cavendish review: an independent review into healthcare assistants and support workers in the NHS and social care settings, July 2013 Back

7   The Standardised Hospital-Level Mortality Index (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). Back

8   NHS England, Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report, 16 July 2013; HC Deb, 16 July 2013, columns 926-29. Back

9   National Advisory Group on the Safety of Patients in England, A promise to learn- a commitment to act: Improving the Safety of Patients in England, August 2013 Back

10   Independent Review of the Liverpool Care pathway, More care, less pathway: a review of the Liverpool Care Pathway, July 2013; HC Deb, 15 July 2013, columns 62-64WS.  Back

11   Ibid, p. 3 Back

12   Ibid, columns 62-64WS Back

13   Oral evidence taken before the Health Committee, Professional Standards Authority for Health and Social Care, 9 July 2013, HC 528 Back

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© Parliamentary copyright 2013
Prepared 18 September 2013