The Francis report can only go so far, the real test will be what we do when nobody is looking, says Anne Marie Rafferty
Nursing occupies a prominent place in the Francis report. The role that nursing plays in setting and upholding standards is to be applauded. Tough talk in enforcing standards and policing by the Care Quality Commission provides a road map for the future.
The report also recommends that the National Institute for Health and Clinical Excellence should provide the tools to support compliance with standards.
This should be a stimulus to speeding up the implementation of evidence-based standards.
NICE is a treasure trove, but an underutilised one with respect to its potential yield for nursing interventions. Similarly, NICE guidance on staffing should help to put the issue onto a stronger evidence-based footing, giving it the authority needed to get traction in the service.
Regulating healthcare assistants would also help to drive up standards and fill the policy void where currently a thousand standards bloom.
Physical inspection by hospital inspectors needs to be accompanied by the physical presence of leaders in care environments. Strengthening the visibility and volume of the nurse leadership voice is a major priority that needs investment and fast-tracking for role modeling, setting culture and shaping governance.
“Strengthening the visibility and volume of the nurse leadership voice is a major priority”
Poor care is the product of poor care environments. These environments may be patchy or more pervasive; but often pockets of poor care co-exist with good or excellent care.
Older people are especially vulnerable in the fast-moving world of the NHS. The Francis report is above all a cri de coeur to rethink how we look after older people in hospitals. Do we need a specialism? I’m not sure. Most people needing care in hospital are older so perhaps we need a special focus on older patients, who are vulnerable and at particular risk with investment in leadership to boost capacity in challenging areas.
Robert Francis recognises the demands of a complex system require the critical skills to stand up for standards and challenge authority. This is best cultivated by a rigorous education to provide the confidence to challenge the status quo.
We know instinctively when we walk into a ward what a good and poor environment is like - how we are greeted, the warmth of the welcome, the eye contact that sense of acknowledgement that we count.
It is what the journalist Malcolm Gladwell talks about in his book Blink. But I wonder how the blink test would stand up to scrutiny in comparison with all the metrics we have created to measure quality in the NHS?
It is not as if we have a shortage of data or systems to measure quality, rather the opposite. But do these capture the sentinel signals of poor care? Are trust boards equipped with the technical skills and know-how to offer challenge and critique? Compassion should be a priority for everyone in the NHS not just nurses.
Culture has also featured prominently in the report. A colleague, Jane Ball, from the National Nursing Research Unit at King’s College London, and I are piloting a culture of care barometer for use in trusts. We are holding focus groups with staff to test out the instrument.
The best definition I have heard about culture was from a nurse in our group: “Culture is what you do when nobody is looking.” We can root out poor practice, enforce zero tolerance and discipline those who observe poor quality but fail to act, but ultimately, as Mr Francis reminds us, it is up to each and every one of us to take responsibility for our own actions. So perhaps we should add another “C” to the CNO’s vision - “conscience”.
The Francis report has much to commend it in its forensic analysis and practical policy recommendations, but regulation and other tools can only go so far, the real test will be what we do when nobody is looking.
Anne Marie Rafferty is professor of nursing policy at King’s College London