This summary looks at how the government has addressed key issues that will affect nursing in its response to the Francis report
The government’s full response to the Francis report, published in November (Department of Health, 2013), covered each of the 290 recommendations point by point (Francis, 2013). While some parts of the response made it clear what was being accepted or rejected, other recommendations were “accepted in principle” - that is, the government accepted there was a problem but devised a different strategy to meet the need.
This article gives a traffic-light summary of the recommendations most relevant to nursing, showing where the government has accepted (green), declined (red) or accepted in principle (amber) each one, and explains what the government is saying it will do, or why it has declined to act.
Registration of healthcare assistants
The Francis Report recommended that any person providing direct physical care should be regulated (this does not apply to informal carers, such as family members).
Response: The government did accept that all people providing personal care should have the right skills to do so. However, it decided that regulating healthcare assistants and support workers would not necessarily prevent poor care and would not improve on the safeguards already in place. Instead, Health Education England, Skills for Care, Skills for Health and other stakeholders have been commissioned to develop a mandatory certificate of fundamental care for HCAs.
Standards for HCAs
The report suggested that the Nursing and Midwifery Council should be responsible for developing a code of conduct, education and training standards and requirements for registration of HCAs.
Response: As said above, the government decided not to regulate HCAs. It also argued that the NMC did not have a remit for developing codes of conduct for social care workers of HCAs.
Dismissing HCAs following breach of code of conduct
Francis called for the Department of Health to develop a nationwide system for dismissing HCAs if they breached their code of conduct to protect patients from harm. It said a system should be designed to provide fair due process for staff dismissed for breaching the code of conduct or for being deemed unfit for the post.
Response: Again, this recommendation was not accepted as the government does not feel regulation of HCAs will improve the quality of care. The disclosure and barring service has instead been implemented to help with recruitment decisions and prevent unsuitable people from working with vulnerable groups.
Criminal offence to obstruct statutory duties
Francis recommended that it should be a criminal offence for any registered nurse medical practitioner, allied health professional or director to knowingly prevent anyone from performing their statutory duties.
Response: The government has declined to introduce this criminal offence. Instead, it plans to improve openness about care failings by ensuring providers abide by this as a requirement of registering with the Care Quality Commission. Professionals who attempt to prevent others from performing their statutory duties (such as raising concerns about care) will be breaching their professional responsibilities and the NMC, General Medical Council and other professional bodies have been asked to make this clear.
Supervisory nurse managers
Ward managers should be supervisory and not office bound.
Response: The government response states that it has accepted this recommendation “in principle”. However, the crucial aspect was that all ward managers should be excluded from ward staffing numbers and this has not been mandated. Instead, care providers are asked to have “local flexibility”. The government accepts that supervisory status and visibility on the wards are important for nurse leadership.
Amber: accepted in principle
Values-based aptitude test for aspirant nurses
Before being allowed to qualify as a nurse, student nurses should be given an “aptitude test” that assesses their attitudes towards caring, compassion and other necessary professional values.
Response: The government is instead making it mandatory for all NHS-funded training posts to include values testing, rather than testing students at the end of the course. NHS England is working with Health Education England and NHS Employers to encourage “values-based” recruitment and appraisals for all staff.
Nurses’ annual learning portfolios
Nurses should show, at their annual appraisal, documented evidence of how they have kept their knowledge of nursing practice and its implementation up to date. This should include feedback from patients and relatives to demonstrate commitment, compassion and caring. This should be signed by the nurse, and countersigned by their appraising manager.
Response: The government believes nurse revalidation will help to keep practice up to date. The NMC is to introduce revalidation, which will require evidence that a nurse or midwife is fit to practise. Its code and standards are to be revised so they are compatible with revalidation.
Registered older person’s nurse
The report recommended that a registered older person’s nurse role should be created to ensure the increasing numbers of older people with complex healthcare needs receive high-quality care.
Response: The government accepts that older people often have complex needs. However, rather than creating a separate branch of nursing, it plans to strengthen this area of training in the existing pre-registration programme. It also acknowledges nurses should be able to specialise in the care of older people and proposes offering access to practical, continuous professional development so nurses do this after qualification.
Standard HCA description
There should be a uniform description of HCAs, made clear by their title.
Response: The government acknowledges that this role can be so varied that a uniform title may not be appropriate. However, the chief nursing officer for England, Jane Cummings, is going to work on developing simplified job roles as part of the career development framework.
Dividing the functions of the Royal College of Nursing
The Francis report suggested that the RCN considered dividing its functions, so that one body takes on its trade union role and a separate body represents the professional.
Response: The government believes this move would improve the authority of the college’s work. However, the RCN itself has decided that it is stronger as a single body as its elements are complementary, and has rejected the recommendation.
Training standards for HCAs
There should be a common set of national standards for HCA education and training.
Response: The national minimum training standards were published this year. Health Education England has been asked to lead work with the Skills Councils, other delivery partners and health and care providers to develop a care certificate for HCAs and other support workers.
Revalidation for nurses and midwives
The NMC should introduce a system of revalidation, similar to the GMC’s, to reinforce the status and competence of nurses.
Response: The NMC has agreed to introduce a “proportionate and effective model of revalidation”. Guidance for this is to be developed and the NMC’s code and standards are being reviewed to ensure they are compatible with revalidation.
Nurse training to include compassionate care giving
Pre-registration education should put a greater emphasis on the practical requirements of delivering compassionate care. All recruits into the nursing professions should have the values and attitudes to offer compassionate care. Nurse leaders should reinforce compassionate values and nurses should receive constant support in providing this.
Response: The government has proposed several ways to do this. First, the NMC has introduced education standards to test students’ literacy, numeracy and communication skills, as well as their “health and good character” before they are accepted onto a nursing course.
Students will need to pass all assessments during their course - they will not be able to make up for poor performance in one area with strong performance in another. The government also mentions “ongoing” work into making a nursing career more accessible for staff who already provide care. Pre-degree care experience is being piloted - see below.
Pre-degree care experience
Aspirant nurses should spend at least three months directly caring for patients under the supervision of a nurse before starting their course.
Response: With the aim of placing emphasis on values from the outset, the government has committed to a pilot programme that sees aspirant nurses working as HCAs for up to a year before they are interviewed for a place on a nursing course. The government believes that students will be able to find out if they really do want to become nurses by gaining hands-on experience as an HCA.
Named nurses for patients
Each patient should be allocated a named key worker responsible for their care each shift. Where possible, this key worker should be present during every interaction between doctor and patient.
Response: The government supports this recommendation. Organisations have been given the option to take action locally on this, although it has not been made mandatory. The Academy of Medical Royal Colleges is producing key principles with worked examples on how this recommendation can be implemented.
Fran Entwistle is assistant practice and web editor, Nursing Times
Department of Health (2013) Hard Truths: the Road to Putting Patients First. London: DH.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.