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Francis response

After Francis: the government response

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Experts comment on aspects of the government’s response to the Francis report that will have a major impact on nursing


The government’s response to the Francis report contained a number of undertakings that will have a major impact on nursing. The measured tone and wide-ranging recommendations of the Francis report gave nurses reason to believe that action would be taken across all parts of the NHS to prevent a similar situation happening again. The government has given its initial response to the report, so what does this mean for nursing? This article summarises key plans for nursing and how they could affect the profession, and experts comment on these plans.

Staffing levels

Jane Ball, deputy director, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London

Talking about nurse staffing levels, a colleague in Australia asked if things are as gloomy in the UK as they seem from afar. Yes, I replied, gloomier. Recent research by King’s College London and Southampton University shows that nurse staffing is related to mortality rates. A daytime ratio of eight patients per registered nurse puts patients at risk, yet we found 40% of acute surgical and medical wards running at this level or worse.

The government clearly understands that nurse staffing is key. It says “adequate staffing levels are essential” and patients need care from “highly trained staff”, but the policies to deliver on this rhetoric remain absent.

We regulate how many children a childminder can care for. We set speed limits. By law, we have to wear seatbelts. But, when it comes to nurse staffing levels, there is no guidance or law. Instead, we must continue to rely on local employers to determine levels. We will continue to monitor mortality rates and advise trusts to monitor their staffing levels too.

Hence my despair: 40% of wards with dangerous staffing levels and a context of increasing money pressures. What impetus is there to improve nurse staffing levels? Definitely gloomy.

Older people

Deidre Wild, independent consultant R&D, older people

In 2001, Help the Aged (now Age UK) and the Royal College of Nursing developed a proposal for a gerontological nursing specialist role, but this was rejected by the government. Twelve years on, and despite the recent strongest evidence yet for this role, yet again it has been rejected. So how can performance be raised, before another decade passes, without this role’s gerontological nursing leadership?

Few nurses on the ward have time to mentor the profession’s students or newly qualified nurses into what could and should be highly skilled gerontological nursing practice. Are we, as a profession, so powerless that we must wait for the next group of prematurely deceased patients to once again shame the system into providing older people with what they most need?

Older people need proactive rather than reactive care, which includes continence promotion rather than induced incontinence, and remobilisation rather than being chairbound.

The intention to put increased focus on older people in pre-registration and postgraduate nurse training is commendable but, without either a specialist career opportunity or the recognition of the specialism of gerontological nursing, once again there is no investment to promote leadership in the care of older people.

This proposal is only another layer of rhetorical pledge that fails to meet what needed to be put in place yesterday for older people, let alone tomorrow.

One-year healthcare assistant experience

June Girvin, pro vice‑chancellor and dean of faculty of health and life sciences, Oxford Brookes University, and member of the Council of Deans of Health

Working as a healthcare assistant before joining a nursing degree programme may be a useful thing to do. At best, it may give a sense of the physical demands of nursing, an introduction to teamworking and an opportunity to see qualified nurses at work. However, at less than best it may establish bad or unsafe habits. A month would be enough to give a useful flavour for those who are unsure.

Nursing education standards already include compassionate care as a core component. Prospective students are already interviewed by NHS clinical staff to help ensure their values are tested. Students spend half their degree programme in university and the other half working in clinical areas. An HCA year would waste precious time for someone who has decided nursing is their future career, and add a considerable burden to the mentoring and supervisory role of nurses.

This proposal shows a disappointing lack of understanding of modern nursing, of professional education and of the NHS workforce. Student nurses make up a tiny proportion of staff. They are continuously monitored and assessed and work under supervision. These are not the individuals who have so badly let patients down.

Rather than wasting time and money focusing on pre pre-registration students, the government and NHS England need to concentrate on getting the right numbers of qualified frontline staff, supported by their leaders to deliver high-quality care.

HCA training standards

Debbie Yarde, chair, Association for Continence Advice

After the powerful testimonies from families of those subjected to the care in Mid Staffs, continence advisers were confounded that bladder and bowel care were not identified in the Francis report as a specific area of concern. This omission means this fundamental element of care will not be specifically included in any subsequent strategies. The proposed HCA regulations echo this.

If avoiding the issue is a fear of upsetting Victorian sensibilities we need to move beyond this - and fast. Being able to pass urine and open your bowels is a fundamental human need. Yes, that need is wrapped up in a requirement for privacy and dignity, but the thought that fitting a pad and then cleaning someone afterwards is enough falls woefully short of the mark.

Without a doubt, the success of the standards will be measured in some way even if efforts are made to avoid targets but, without specific reference to continence, this will once again become the missed opportunity.

Duty of candour

Elaine Maxwell, assistant director, the Health Foundation

There is a moral imperative, even a human right, for people to be informed of any act or omission that has directly caused them harm. However, it is not at all clear what the introduction of a statutory duty to do so means in practice.

Criminal and civil prosecutions are already available for accountability and redress of the harm itself. A statutory duty of candour, on the other hand, requires the disclosure of errors before liability is considered.

The purpose of a duty of candour is to ensure open and early disclosure of errors. Without clarity about the nature of errors covered by the duty, it will be important to ensure there are no unintended consequences. The impact of a criminal duty is likely to create a culture of fear and some foresee potential under-reporting (in clinical records as well as incident reports). For this reason, it is wise to be cautious of enacting a criminal duty of candour for either organisations or individuals.

Placing a civil law duty at organisational level will require boards to consider systems and culture but could absolve individual practitioners from personal responsibility for disclosure, so the levels at which the duty applies will need careful consideration. In England, a contractual duty of candour for NHS organisations came into force on 1 April. This will be an opportunity to test how the service responds in practice before deciding what sort of statutory duty is required.


Marion Collict, director of transformation, Luton and Dunstable University Hospital Foundation Trust

What does the government response to the Francis report tell us about Jeremy Hunt? He clearly lacks courage; courage to look beyond the surface, courage to look beyond the symptoms.

Intentional rounding is not new. The concept has taken many guises over the years but nurses have always known the importance of position change, skin checks, regular toileting and so on. The reality is that in hospital wards up and down the country, nurses are rarely able to undertake these activities routinely and delegate them to HCAs. HCAs often work unsupervised while registered nurses are distracted by many other activities keeping them away from the bedside.

An industry of paperwork has been created to provide assurance that care has been delivered and this has resulted in our tick-box culture. Nothing in the government’s proposal tackles the fundamental problem of the empty space at the patient’s bedside - the rightful place of the nurse and the root cause of the decline in standards of essential nursing care.

Nurses, now as much as ever, are compassionate and want to nurse and care for their patients. We have created a situation that must be reversed. We must create a model of care that is sustainable, and meets the needs of patients, staff and regulators. This bold approach requires courage - something that Mr Hunt does not appear to have enough of.

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