The first “Francis report” published three years ago gives us some insight into what we can expect the barrister to focus on in his long-awaited second report this week, says Jenni Middleton.
The Mid Staffordshire NHS Foundation Trust public inquiry report is due to be published tomorrow, the 6 February – almost three years to the day since the findings of Robert Francis QC’s independent inquiry into the trust were published on 24 February 2010.
The QC’s independent inquiry was different to the public inquiry in that it heard evidence behind closed doors.
It also focused specifically on the care failings that occurred at Mid Staffs, while his second inquiry focused more on the NHS as a whole and why its governance and regulatory systems allowed the problems at the trust to persist without being identified or tackled.
However, despite the subtle differences between the two inquiries, Mr Francis’s first report may offer some clues about the second. The independent inquiry unearthed a huge amount of material he highlighted as of help to the wider NHS in learning from the “appalling experiences” at Mid Staffs.
Based on the recommendations of the first Francis report, here are six areas that he may cover in his second report this week.
1. A focus on delivery of care
This was a fundamental part of the initial independent inquiry, and it is likely that Francis will re-emphasise this throughout his second report.
His first recommendation in the independent inquiry report was that Mid Staffordshire Foundation Trust “must make its visible first priority the delivery of a high-class standard of care to all its patients by putting their needs first”.
This is the essence of what the public inquiry was about, and Mr Francis is likely to focus on this as the key guiding principle in all his recommendations tomorrow.
Strongly linked to delivering high class care is having sufficient staff to do so. Much has been written about whether Mr Francis will recommend minimum staffing levels; for example, a minimum nurse: patient ratio or nurse: healthcare assistant ratio.
This subject was discussed often during the public inquiry, with several high profile witnesses asked for their views on it, including the then chief nursing officer for England Dame Christine Beasley.
However, it seems unlikely that Mr Francis will stipulate minimum staffing numbers given that the evidence presented to him by some senior nurses gave an equivocal evidence base for its introduction, and the government has previously shown great reluctance to go down this route.
But he is likely to say something about the importance of sufficient staffing, and paying attention to the number of qualified nurses available for patient care.
2. Regulation of managers
A lot of the care failings at Mid Staffordshire FT were blamed on systemic failure – and confusion between senior managers about who was taking responsibility for strategic rather than operational issues.
Indeed, a lot of criticism has been around the trust’s focus on achieving foundation trust targets at the expense of day-to-day care.
Even during his previous independent inquiry, which was sharply focused on the trust itself, Mr Francis noted his feeling that it was a problem in the wider NHS.
Indeed in the first report, he wrote in Section D, point 76: “Finance, in the sense of the resource made available to the trust, must always be the servant of the trust’s purpose – the delivery of good and safe care – and not the master which dictates the standard of delivery, however poor.”
But how might he frame this in his fresh set of recommendations tomorrow? There is some debate around whether managers will be put on a register to ensure they act on escalated concerns and maintaining patient safety in a timely manner. A negative register has been mooted as one option, with managers only added to it if they have proved themselves incapable of meeting required standards.
3. Protecting those who speak out
Mr Francis has commented on how few employees felt able to speak up about the poor care they had seen at Mid Staffs when he invited them to give evidence in his first inquiry, and how their concerns were dismissed when they escalated them to management.
Evidence was heard suggesting that literally hundreds of incident reports from frontline staff were thrown in the bin.
In Section B of the first report, he talks about bullying. Point 37 he states: “I heard much evidence suggesting that members of staff lived in an atmosphere of fear of adverse repercussions in relation to a variety of events. Part of this fear was promoted by the managerial styles of some senior managers.”
It is likely that he will say something tomorrow about people being able to speak out when they identify poor care, and will want to try and make changes to the way whistleblowers are handled in the NHS.
A “duty of candour” has already been added to the NHS Constitution but Mr Francis may want something more legally binding.
4. Mandatory minimum training for healthcare assistants
Many patients at Mid Staffs failed to have some of their most fundamental needs met – they were left in soiled beds, without water and meals out of reach.
Section A of the independent inquiry report was probably the most shocking concerning these failings, and would have ensured Mr Francis knew the importance of getting this clinical care right.
That section of the report lists all the fundamental areas of care that nursing staff must perform with competence, including privacy, dignity, pressure area care, oral hygiene and hydration.
While training is not seen as the solution to a lack of care and compassion to get this right – it is likely that increasing training for healthcare assistants will ensure they are able to step up to perform more of these nursing duties competently.
Skills for Health are already in the process of developing training standards for HCAs, at the request of the government. But whether this approach will be viewed by Mr Francis as having sufficient weight is open to question. He may call for a stronger and broader approach.
5. Regulation of healthcare bodies
This is the one that everyone is holding their breath over.
Healthcare regulatory bodies including the former Healthcare Commission – succeeded by the Care Quality Commission – and Monitor, the foundation trust regulator, were criticised by the first Francis report for failing to identify issues in care standards.
The report strongly hinted in its executive summary that Mr Francis felt healthcare regulation needed a more detailed investigation in future.
It states: “The inquiry has received a considerable number of representations that there should be an investigation into the role of external organisations in the oversight of the trust.
“While such an investigation is beyond the scope of this Inquiry, local confidence in the trust and the NHS is unlikely to be restored without some form of independent scrutiny of the actions and inactions of the various organisations to search for an explanation of why the appalling standards of care were not picked up.”
Mr Francis subsequently got his wish, as regulation featured heavily in the terms of reference of the public inquiry.
It is highly likely that he will use his report tomorrow to try to strengthen the regulatory bodies.
He will also be keen to want to improve the process by which failing hospitals are identified, and increase the independence with which they operate.
6. A change in culture
Culture is a word that has featured a lot in the run up to the publication of the public inqury’s findings. Improving the management and leadership in trusts will enhance communication and lead to early identification of issues.
But Mr Francis could recommend going further – for example, opening up trust meetings to the public more formally to ensure that local residents and staff know what is going on at board level. This could also make for a more transparent NHS.
The first Francis report revealed lots of stories of patients’ relatives being too scared to complain or ask for help for their relatives because of fear of reprisals – these are in Section B: the culture of the trust.
As a result, in his second report, he could also recommend a rigorous complaint handling and reporting procedure, which involves fast action to protect the public as the first report indicated a serious failing in the complaint handling procedures.