Sir Robert Francis QC has warned financial and demand pressures on the NHS have created an environment in which a care scandal equal to that at Mid Staffordshire is “inevitable”.
In an in-depth interview to mark the fourth anniversary of the publication of his landmark report, Sir Robert said the NHS was facing an “existential crisis”, and was “manifestly failing” to keep pace with demand.
“Let’s make no bones about it – the NHS is facing an existential crisis”
Sir Robert highlighted the failure of national leaders to recognise growing threats to patient safety that were being created by policy decisions, identifying a “disconnect” between what national leaders claimed was happening and experience on the front line.
Decisions were being made “more and more remotely” from those who actually look after the patients, he told Shaun Lintern in an interview for Health Service Journal.
Sir Robert said he was still worried about staff, including those in senior roles, feeling they were not being listened to.
He also said there was still an emphasis on “good news stories” in the NHS, echoing concerns he raised around Mid Staffs that national leaders only wanted to tell positive stories about the service and were ignoring concerns when they were raised.
He warned that unless NHS leaders continued to focus on the specific lessons from the scandal, there would be a “a real danger of a relapse.”
It was becoming increasingly clear that the NHS was failing to meet the demands it faces from patients and a “serious decision” needed to be made on funding, he added.
“There will come a point where public confidence in the service dissipates”
Measures outlined in NHS England’s Five Year Forward View and the 44 regional sustainability and transformation plans were “unrealistic”, Sir Robert warned.
“Let’s make no bones about it – the NHS is facing an existential crisis. That may have been said before, but now it really is,” he told Health Service Journal.
“We can’t stop the population or needs growing. The service is running faster and faster to try and keep up and is failing – manifestly failing,” said Sir Robert.
He added: “The danger is that we reach a tipping point – we haven’t reached it yet – but there will come a point where public confidence in the service dissipates.”
Asked whether the same mistakes that caused the failings at Mid Staffs could happen again, Sir Robert said it was “inevitable” if trusts that were financially strained agreed to performance targets they could not afford.
“If you look at the number of trusts who are not only in deficit but won’t agree their control targets, the fact some are not agreeing their control targets is good because it means they are saying we can’t actually do that and carry on the service you want us to provide,” he said.
“But there will be those that have said ‘yes’ when they actually can’t do it. Absolutely yes, that is a danger,” he warned.
“There is a frontline feeling that things have never been as bad as they are now”
He welcomed recent changes in “corporate attitudes”, which he said were much more focused on patient needs and that there was greater transparency about where problems in the service existed.
But Sir Robert, who is a non-executive director at the Care Quality Commission, added: “That is not to say the pressures to tell the good news stories and emphasise those isn’t still there.
“The higher up the national tree you go the more I would suggest that is the case,” he said. “I feel there is an ever increasing disconnect again between what nationally is sometimes said to be going on and what people on the ground feel or see is going on.
“Politically, with a ’small p’, the message is put out that we are putting more money into the service than we ever did and it is the best health service around, but against that there is a frontline feeling that things have never been as bad as they are now and we can’t deal with the pressures.”
Asked whether he believed the risk of a collapse in patient safety was “adequately recognised at senior levels”, Sir Robert said: “I honestly don’t know”.
He was relatively positive about the new regulator NHS Improvement, whose executive chief nurse Dr Ruth May has recently acknowledged the extreme pressures that nursing staff are currently under.
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“I would like to think there is more acceptance at NHS Improvement level than perhaps there has been in the past, and I think there is an approach and understanding of the importance of keeping the quality agenda going,” said Sir Robert, adding that he thought it also “permeates the Department of Health”.
Sir Robert reflects on progress with nursing recommendations
In addition, Health Service Journal asked Sir Robert to reflect on reforms carried out since his report into the Mid Staffordshire scandal was published 2013 and highlight areas where he believed further work is still needed to safeguard patient safety. Here is a summary of his comments most relevant to nursing:
Sir Robert said there was a “looming workforce crisis that is here now and Brexit is not going to help.” He said: “What we need is more nursing. But we are told ‘oh well we have got more nurses’ – no nursing director I have come across seems to agree with that and they can’t find them.”
He maintained his view that minimum staffing ratios were not a solution, saying: “I know there is evidence that would support it in some places but this is all about providing for the needs for your patients on any given day and in any given ward and no patient is a rule of thumb.”
But he said recent guidance from NHS Improvement was “suspiciously” similar to the work by NICE which was suspended in 2015.
“I think the sort of methods being advocated in some of the guidance of aggregating the needs of your patient to produce a number of hours is a good start,” he said. ”I am not saying care hours per patient day is the answer, but it is actually a tool and if you regard it as that and you use it as a method of comparison I don’t see any harm in that.”
On the nursing voice
Sir Robert said: “I think nursing is badly served, and patients are badly served by the diminution of the nursing voice. I have yet to see a good reason why there is not a chief nurse equivalent to the chief medical office in the Department of Health. Look at the current state of affairs where the nursing director of NHS Improvement says we haven’t got enough nurses and the response to that is we have. When the simple answer is we haven’t.
“I think we have had four years of doing it this way, I think it is a good idea for it to be looked at again,” he said. “Nursing is such an absolutely important critical part of the workforce. If you don’t have that voice at the heart of government it will be forgotten.
“The chief nurse is never going to be the whole of the answer, the profession needs a more effective professional voice as opposed to a trade union… particularly at a time when it is becoming more difficult to recruit nurses and challenges how you train them,” he said.
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On nursing associates
Sir Robert said: “I think there needs to be some careful definition about what a qualified nurse can do that others should not do. You can say the same about HCAs and registered nurses.
“To have a career structure and entry into the profession is good and professionalises something that otherwise isn’t, so I think that is good,” he said.
“The danger is you expand those roles beyond what they were set up to do and slowing they take over things which do require the skills of the more trained individual and it’s difficult to keep a handle on that,” he added.
Regulation of HCAs
Sir Robert said it was still his view that healthcare assistants should be subject to some form of registration, as decribed in his report.
He added: “I always felt that there needed to be some safeguards around HCAs, which registration would provide. The idea, apart from committing some serious criminal offence, that you can just drift from one place to another without anyone knowing much about you I find quite alarming.
“The point about HCAs is that they do an extraordinarily valuable job with very vulnerable people,” he said. ”They do it for very low pay and one of the purposes for registrations and certification was to give them a sense of professionalism.”
What was the Francis report?
In February 2013, Sir Robert published his three-volume report following the public inquiry into events at Stafford Hospital, part of the former Mid Staffordshire NHS Foundation Trust now known as University Hospitals of North Midlands NHS Trust.
The report concluded hundreds of patients had experienced “appalling and unnecessary” suffering, largely as a result of too much emphasis being placed on saving money instead of care standards.
He made 290 recommendations to bring about a cultural change in the health service. It followed an independent inquiry by him into Mid Staffs published in February 2010.