The Francis report, published February 2013, contained the long-awaited findings of the public inquiry into Mid Staffordshire Foundation Trust. Sarah Calkin answers some frequently asked questions about it.
- What is the Francis report?
- Why has there been a public inquiry into Mid Staffordshire Foundation Trust?
- What happened at Stafford Hospital?
- Why was care so poor at Stafford Hospital?
- Why were the trust’s failings allowed to persist for so long?
- Why does the inquiry matter to nursing?
- What is the Francis report likely to recommend?
- Will the government implement the Francis report’s recommendations?
- Who will the public inquiry criticise?
- When will the report be published?
1. What is the Francis report?
Robert Francis QC is a barrister with extensive experience of clinical negligence claims.
He recently chaired a public inquiry into how poor care at Mid Staffordshire Foundation Trust was allowed to happen in the period between January 2005 and March 2009, and why none of the organisations responsible for regulating or managing the trust spotted problems sooner.
The inquiry was held in public between November 2010 and December 2011. The findings from the inquiry are due to be published this week in a document widely referred to as the “Francis report”.
It will, however, be Mr Francis’ second report into what happened at Mid Staffordshire Foundation Trust. The first was based on an independent inquiry, which was held behind closed doors.
It was published in February 2010 and focused on the failings of the trust itself, rather than those in the wider NHS system.
2. Why has there been a public inquiry into Mid Staffordshire Foundation Trust?
The poor standards of care exposed at the trust’s Stafford Hospital made national headlines in 2009 and horrified the public and NHS staff alike.
Members of local campaign group Cure the NHS – many of whom have relatives that died at Stafford Hospital – repeatedly called for a public inquiry into events at the trust and their broader context in the NHS.
They complained that the previous independent inquiry – established by former Labour health secretary Andy Burnham and chaired by Robert Francis QC – was insufficient in scope and transparency.
Andrew Lansley, who was health secretary from June 2010 till September 2012, made a commitment that he would commission a public inquiry while the Conservatives were in opposition.
He was good to his word when he took office following the last general election. He announced a full public inquiry on 9 June 2010.
3. What happened at Stafford Hospital?
The Healthcare Commission – the forerunner of the Care Quality Commission – exposed appalling treatment and high mortality rates at the hospital.
It was widely reported in the media that an estimated 400 to 1,200 people could have died unnecessarily there between 2005 and 2008, though these figures were never formally published by the commission.
In his previous independent inquiry, Mr Francis estimated the deaths ranged into hundreds, with around 500 occuring between 2005-08.
The public inquiry heard common themes of call bells going unanswered, patients left lying in their own urine or excrement, or with food and drink out of reach. Patient falls were also concealed from relatives.
In addition, the inquiry heard that receptionists in the accident and emergency department had regularly triaged patients.
Many patients and relatives also reported being treated with callousness by nursing staff.
4. Why was care so poor at Stafford Hospital?
The first Francis report, published in 2010, listed historic understaffing of nurses as one of a number of reasons for poor care.
It also highlighted a bullying culture at the trust and said that senior managers were in denial about the extent of the problems there.
Posts were cut and the wards were reorganised into a money-saving “clinical floors” system. The skill mix ratio of registered nursed to healthcare assistants ratios dropped as low as 40:60 in some areas.
Staff and patient concerns were repeatedly ignored by senior management in favour of balancing the books.
There was a perception that managers were more focused on the organisation attaining foundation trust status than on quality of care.
In his first report, Mr Francis specifically criticised the trust for being obsessed with obtaining foundation trust status and meeting targets rather than patient care.
The document stated: “The inquiry chairman, Robert Francis QC, concluded that patients were routinely neglected by a trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care.”
5. Why were the trust’s failings allowed to persist for so long?
Both internal and external reasons are implicated for the failure to identify or tackle the problems at Stafford Hospital.
The previous independent inquiry painted a picture of an inward looking organisation, with a low staff turnover. The trust suffered from a lack of new ideas and a negative culture that became entrenched, it concluded.
Different layers of NHS hierarchy above the trust have also been criticised for failing to address the situation.
For example, the public inquiry heard criticisms of South Staffordshire Primary Care Trust, which was responsible for overseeing the commissioning of services for the Mid Staffordshire area.
The PCT was more focused on financial problems at the bigger teaching hospital up the road, University Hospital of North Staffordshire NHS Trust, the public inquiry was told.
In addition, NHS West Midlands, the regional strategic health authority, was said to have suggested high mortality rates at the trust were the result of data errors, rather than evidence of poor care.
6. Why does the inquiry matter to nursing?
At the heart of what happened at Mid Staffordshire Foundation Trust is poor nursing care.
However, the scope of the public inquiry extends well beyond the actions of the nurses at the trust itself.
The second Francis report will look at how the set-up of the entire health and social care system in England can help or hinder nurses and other staff to deliver good care.
It will also focus on the culture of the NHS and the impact that has on the ability of staff to raise concerns.
7. What is the Francis report likely to recommend?
Mr Francis gave a good idea of the broad areas he would make recommendations on during the final day of the public inquiry.
- staffing levels and skill mix;
- protection of whistle blowers;
- training and regulation of healthcare assistants;
- recruitment, training and standards of registered nurses;
- the specific training of staff caring for older patients.
Only Mr Francis and a select group of advisers know for certain exactly what he will recommend.
However, he showed great interest in improving the overarching culture of the NHS and seemed shocked by the lack of checks surrounding healthcare assistants.
8) Will the government implement the Francis report’s recommendations?
The government is under no formal obligation to implement Mr Francis’ recommendations.
But it will be politically very difficult for the current health secretary, Jeremy Hunt, to ignore it.
The report will deal with many issues of significant interest to the public – and therefore potential voters – and will gain widespread attention from the national media.
In addition, more than £15m of public money has been spent on the public inquiry’s running costs and legal fees.
However, the government’s opposition to the statutory regulation of healthcare assistant and introduction of minimum staffing ratios could put it in a difficult position, should these be measures recommended by Mr Francis.
It is expected the government will give an initial response to the report when it is published this week, with a more detailed response a few months later.
The government is already considered to have taken some pre-emptive action ahead of the report.
This includes the publication in December of the national nursing strategy, Compassion in Practice, which includes the “6Cs”, and a commitment earlier this month to roll out the “Friends and Family” test of patient experience across the NHS.
9) Who will the public inquiry criticise?
The problems at Mid Staffordshire Foundation Trust happened during the previous Labour administration, so the current Coalition government is likely to escape any direct criticism.
But Andy Burnham, former Labour health secretary and current shadow health secretary, could face criticism for approving the trust’s bid for foundation trust status in 2008.
Sir David Nicholson, the chief executive of the NHS Commissioning Board, is expected to be criticised for his role in determining the overall culture of the NHS and also for oversight failures while he was head of the West Midlands strategic health authority.
Some patient groups are already calling for him to resign, but Sir David has publicly said he wants to hold the position for the next few years.
Many senior nurses may also face criticism in the report. Former trust director of nursing Helen Moss is likely to be rebuked for not addressing staff shortages with urgency when she joined the trust in late 2006.
NHS West Midlands chief nurse Peter Blythin, who is now nursing director at the NHS Trust Development Authority, may also be pulled up for not addressing staffing issues at the trust.
In addition, Royal College of Nursing chief executive and general secretary Peter Carter could face a rough ride.
He publicly praised standards of care on some wards after visiting the trust on the same day the Healthcare Commission had, unbeknown to him, identified serious issues in others parts of the organisation.
10. When will the report be published?
Following weeks of speculation, Mr Francis has confirmed that he plans to publish his public inquiry report on Wednesday 6 February.
He has said he will share the document with health secretary Jeremy Hunt the day before.
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