The nursing profession and its leaders have failed to adequately respond to the problems highlighted by the care failings at Mid Staffordshire, according to Robert Francis QC.
The views expressed by the chair of the Mid Staffordshire Foundation Trust Public Inquiry are likely to make uncomfortable reading for those charged with leading the profession.
Mr Francis has spoken exclusively to Nursing Times and our sister magazine Health Service Journal in his first in-depth interview since the publication of his landmark report in February.
He said his “impression” was that his report had been “well received by all the [healthcare] professions in general terms”.
Individually he had held “lots of conversations” with nurses, he said. These indicated “many nurses get the point” made in his report about the need for the profession to speak up for itself more.
But he criticised what he perceived as a lack of collective response from the profession as a whole and its representatives.
He compared the response to his recommendations from NHS managers and doctors’ leaders, saying: “They are taking this very seriously. The [medical] royal colleges are taking action.
“Putting it bluntly I have seen rather less of that from the nursing profession,” he said.
Mr Francis claimed he had seen “no reaction” to his call to strengthen the voice of nursing in order to speak up for frontline staff and prevent catastrophic care failings.
“I’m still not sure in terms of the professional voice I have heard much that gives me cause for optimism,” he told Nursing Times, noting that he understood concerns about needing to protect nursing staffing levels.
“There is a need to strengthen the voice of nursing so that what nurses need in their workplace to do their job effectively for patients is articulated better and stronger,” he said.
Mr Francis also cautioned nurses against complaining they were being unfairly focused on by ministers and the media, following the publication of his report.
“Any individual or group who says it’s not fair we are being criticised and someone else isn’t are missing the point,” he said. “The first and foremost duty any professional has is to fulfil their own responsibility and if that’s been shown not to happen their responsibility is to put that right.
“It isn’t a justification for inaction now for a nurse to say I’ve been criticised and doctors haven’t.”
In addition, he said there had been an “apparent misunderstanding” over his recommendations on staffing levels, and suggested unions had “got the wrong end of the stick”.
“I did not recommend there should be a national minimum staffing standard for nursing. The government was criticised for not implementing one, which it is said I recommended, which I didn’t.”
Instead, he said had recommended that the National Institute for Health and Care Excellence draw up staffing guidance “for each speciality on a service by service basis”, which he described as the “way forward to be more flexible”.
However, Mr Francis was equally critical of the government’s reluctance to bring in mandatory regulation for healthcare assistants, which he said was endangering patient safety.
“Without any registration system or its equivalent, I believe the public will be at risk. I am impressed by the fact that virtually every professional group including HCAs themselves consider this ought to happen,” he said.
“There seems to be everything in favour of it and if – as one survey suggested – they would be willing to pay for it themselves, I’m not sure what the problem is,” he added.
He did welcome the government’s commitment to national training standards for HCAs, but cautioned that it did not go far enough on its own. “We train doctors and nurses and we still like to keep tabs on them afterwards. I think the same should apply with healthcare assistants,” he said.
Mr Francis said the “jury is out” on the government’s plans to make student nurses work for up to a year as an HCA before starting their degree course.
His report has recommended a similar idea, but with potential students working in care settings for around three months. He defended the proposal saying a minimum period of hands on care was “essential” to “test a nurse’s aptitude”.
Mr Francis also used the interview to restate his view that NHS staff guilty of the most serious types of poor care – those resulting in serious injury or death – should face the threat of criminal prosecution.
Describing a scenario where such a prosecution might take place, he said: “I’m talking about the sorts of behaviour we saw so many distressing examples of in Stafford. Of absolutely appalling care, insulting to human dignity and in some cases life-threatening behavior – leaving people naked, unfed, covered in faeces.
“I refuse to believe that in some of these cases it was not possible for staff to do something about the dreadful things that were happening.”
He said the existing system of rules and regulations had failed to prevent the scandal at Stafford and new criminal offences were needed to properly “reflect the rightful anger and horror the public have about such things”.
Prosecutions would only happen, he said, if it was shown individuals could have been reasonably expected to have prevented it and did not. “We are not talking about the poor nurse who is so rushed off her feet, because she has inadequate support, she can’t look after all her patients,” he said.
Without the introduction of such laws, Mr Francis warned that public confidence in the NHS “will evaporate”.
“There is huge resilience among the public in terms of its trust of the NHS, but too many Mid Staffordshires and I am afraid you will find that going,” he warned.
The government has said it will await the outcome of a major review of NHS patient safety before making a final decision on criminal sanctions. The review, led by US patient safety expert Professor Don Berwick, started last month and is due to report its findings in July.
In a response from the government, health minister Dr Dan Poulter said: “We’ve been absolutely clear that the Francis Inquiry needs to be a catalyst for change in the NHS - and have swiftly brought in measures to improve the quality of care patients receive and ensure they will be treated with more compassion and respect.
“But in other areas, such as criminal sanctions or a duty of candour on individuals, we need to be careful that we do not unintentionally create a culture in hospitals that is less open, rather than more. We are considering these issues carefully.
“Regulation in itself is no substitute for a culture of compassion and effective supervision. Instead we are focused on recruiting the right people with the right skills for the job, and creating a culture that supports them to give safe care.”
The Royal College of Nursing said it would issue a “detailed and comprehensive” response to the Mid Staffordshire Foundation Trust Public Inquiry report in June, which would be based on the views of its members.
In a statement, it said: “We take the findings extremely seriously, not only in terms of how they will impact on the nursing profession as a whole, but also as an organisation that seeks to represent the interests of nursing staff and their patients.”
· See next week’s issue for further response to Mr Francis’ comments from nursing leaders and other key stakeholders.