Analysis: Francis report to lift lid on how poor care could persist
Sarah Calkin looks at why the report into failings at Mid Staffordshire Foundation Trust will have implications for all nurses, as well as for the entire health and social care system.
The report into care failings at Mid Staffordshire Foundation Trust will have implications for all nurses, as well as for the entire health and social care system.
Nursing has rarely been out of the headlines in the past 12 months as story after story of poor care in the country’s hospitals and care homes has been highlighted by the national media.
That is not about to change anytime soon with the imminent publication of the report of the Mid Staffordshire Foundation Trust public inquiry set to cast the spotlight on nursing once more.
Chaired by Robert Francis QC, the inquiry into how the regulatory system failed to spot problems at the Midlands’ trust began more than two years ago. Over 37 weeks the inquiry heard evidence from more than 180 witnesses, at least 14 of whom were registered nurses.
It heard how the relatives of patients on two wards in particular had often found their loved ones unwashed, unfed and even left lying in urine or excrement. Despite nurses at the trust filing almost 1,000 incident reports about dangerously low staffing levels, the trust went at least two years with a vacancy rate for nurses of more than 10%.
The inquiry also heard from Helene Donnelly, an accident and emergency nurse at the trust who described seeing numerous patients die without dignity. At the other end of the spectrum, former chief nursing officer Dame Christine Beasley also gave evidence to the inquiry on the national state of nursing and its regulation.
Currently only Mr Francis and a select group of advisers appear to know exactly what he will recommend in order to try and ensure failure on the scale of Mid Staffs does not happen again.
Professor Jill Maben, director of the National Nursing Research Unit at King’s College London, told Nursing Times the Francis report had the potential to be a “watershed moment” for nursing.
She hopes it will lead to more recognition of the emotional impact on nursing staff and their need for support.
“One of the symptoms of burnout is depersonalisation and seeing people as numbers,” she said. “If you’re in an environment where you know in your heart you’re not able to provide good quality care people switch off and think ‘what’s the point?’.”
While she is clear the failings at Mid Staffs were not just about nursing, Professor Maben said nurse leaders who did not read the report were not doing their jobs.
As part of the inquiry, Mr Francis held a day long seminar on nursing which considered latest evidence on minimum staffing levels, skill mix ratios and the regulation of healthcare assistants. All three issues divide the profession and are actively opposed by the government, which has previously been reluctant to set mandatory rules for minimum staffing levels and HCA regulation – despite pressure from unions and other stakeholders.
It could face almost unavoidable pressure should the Francis report call for action on these issues. Although ministers are not obliged to implement Mr Francis’ recommendations, it will be politically difficult not to do so – having set up the public inquiry on taking office in 2010, and the high public and media profile of the subsequent report.
Whether Mr Francis backs the introduction of some or all of them, or rejects them outright, the impact on nursing will be significant.
Mr Francis is also expected to make recommendations on improving the protection of whistleblowers and the education and training of those caring for the older patients.
Sir Stephen Moss is a nurse and former trust chief executive. He was made chair of Mid Staffordshire Foundation Trust when the former post holder resigned at the height of the scandal there. He believes there needs to be a cultural shift in how we approach caring for older people.
“We seem to have gone a long way to recognise that children have got special needs. We need to put that sort of investment in teaching nurses about the normal processes of aging and special needs of elderly patients,” he said.
Sir Stephen told Nursing Times the most striking thing on joining the trust was the variation in quality of care between wards, a fact he believes demonstrates the importance of culture at a micro level
“We need to be brave enough to start moving away from initiatives,” he said. “We need to take stock of what we have to do to make sure we create the right environment all of the time.”
The trust’s current director of nursing and midwifery, Colin Ovington, told Nursing Times that he found a culture of “learned helplessness” when he joined the trust in June 2010.
For example, he recalls a ward sister in tears after all ward managers were asked to order extra water jugs to ensure patients still had access to water when one set of jugs was washed.
“Management had been preventing staff from ordering clinical supplies. By the time I got here they didn’t know how to do it,” he explained.
Mr Ovington said the new national nursing strategy for England – Compassion in Practice – which sets out the 6Cs which all nurses should embody – care, compassion, courage, commitment, communication and competence –
get to the “nub” of some of the things that went wrong at Stafford by getting back to the basics of nursing care.
“Nurses around the country tell me elements of what happened here happened elsewhere. The difference here is that it all happened in one place in a period of time,” he said.
“It’s important that nurses understand what went on here to try and prevent it from happening where they work,” he added.
In total 55 nurses who worked at Mid Staffs during the period the inquiry focused on – 2005 to 2009 – have been investigated by the Nursing and Midwifery Council. Most cases are still ongoing, including that of Jan Harry, who was nursing director through most of the period under consideration. No nurses have yet been struck off.
Mr Francis will also examine the fitness to practise functions of professional regulatory bodies, including the NMC. He is expected to criticise the existing system, which the inquiry heard made it difficult to dismiss poorly performing doctors and nurses.
Many point out that the system the inquiry was set up to examine has changed drastically in the past two years following the introduction of the 2012 Health and Social Care Act. However, Mr Francis is likely to focus his recommendations on cultural change rather than structural reorganisation.
Even before the publication of the report, the inquiry is having an impact in Westminster. During recent months the government has announced a number of initiatives, which appear to anticipate Mr Francis’ recommendations. The national roll out of the “friends and family” test, for example, reflects Mr Francis’ commitment to consider how patient voice could be embedded in the system.
In addition, a commitment from new national training body Health Education England to increase the focus on values when recruiting undergraduate nurses is an attempt to address some of the perceived cultural issues.
Like many, Professor Maben questions whether prime minister David Cameron would have set up the Nursing and Care Quality Forum without the impetus of the Francis report.
The forum’s chair, Sally Brearley, told Nursing Times it was important to note the profession had not been “standing back” waiting for the Francis report but was already moving to address the issues.
“I hope that immediately it is published, there won’t be a knee jerk reaction – a rush to “do something, anything” – to show we have responded. Any proposals for change need to be tested against evidence that they will work.”
Whatever criticisms and recommendations are contained in the Francis report this week, they are likely to impact on nursing at every level and in every setting, and therefore cannot be ignored.
What is the Francis report?
The Mid Staffordshire Foundation Trust public inquiry was held between November 2010 and December 2011.
Barrister Robert Francis QC chaired the inquiry into how serious care failings were allowed to occur at the trust between January 2005 and March 2009, and why none of the organisations responsible for regulating or managing the trust intervened sooner.
The findings from the inquiry are due to be published on 6 February in a document widely referred to as the “Francis report”.
It will be Mr Francis’ second report into what happened at the trust. The first was based on an independent inquiry, held behind closed doors, which was published in February 2010.
Why does the inquiry matter to nursing?
One of the key areas under scrutiny from the inquiry was poor nursing care at Mid Staffordshire Foundation Trust. However, the scope of the public inquiry extends well beyond the actions of the nurses at the trust itself.
The 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.
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