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Cultivating a culture of compassion
The final report into the failings of Mid Staffordshire NHS Foundation Trust by Robert Francis QC concluded that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care. In the report, Francis made recommendations for both the Trust and government on how to improve patient care and prevent such failings in the future.
The government has now responded to the report, pledging to overhaul of the health and care system so the quality of patient care will be put at the heart of the NHS.
On release of the government’s initial response to the report, ‘Patients First and Foremost’, Health Secretary Jeremy Hunt said: “The events at Stafford Hospital were a betrayal of the worst kind. A betrayal of the patients, of the families, and of the vast majority of NHS staff who do everything in their power to give their patients the high quality, compassionate care they deserve.
“The health and care system must change. We cannot merely tinker around the edges – we need a radical overhaul with high quality care and compassion at its heart. I am setting out an initial response to Robert Francis’ recommendations. But this is just the start of a fundamental change to the system.
“I can pledge that every patient will be treated in a hospital judged on the quality of its care and the experience of its patients. They will be cared for in a place with a culture of zero harm, by highly trained staff with the right values and skills. And if something should go wrong, then those mistakes will be admitted, the patient told about them and steps taken to rectify them with proper accountability.”
Robert Francis’ final report is based on evidence from over 900 patients and families who contacted the Inquiry with their views. It clearly shows that for many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid. Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding. Staff failed to make basic observations and pain relief was provided late or in some cases not at all.
Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards. The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.
Speaking at the publication of his final report, Robert Francis QC said: “I heard so many stories of shocking care. These patients were not simply numbers they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”
The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care. Morale at the Trust was low, and while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients. Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying.
Robert Francis QC added: “It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out.”
The Inquiry concluded that a number of the deficiencies at the Trust had existed for a long time. Whilst the executive and non-executive Board members recognised the problems, the action taken by the board was inadequate and lacked an appropriate sense of urgency.
The Trust’s board was found to be disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients. The Trust failed to listen to patients’ concerns, the Board did not review the substance of complaints and incident reports were not given the necessary attention.
Problems at the Trust were exacerbated at the end of 2006/07 when it was required to make a £10 million saving. The Board decided this saving could only be achieved through cutting staffing levels, which were already insufficient. The evidence shows that the Board’s focus on financial savings was a factor leading it to reconfigure its wards in an essentially experimental and untested scheme, whilst continuing to ignore the concerns of staff.
NO MORE EXCUSES
Announcing the Inquiry findings, Mr Francis told staff and patients: “A number of staff and managers at the hospital, rather than reflecting on their role and responsibility, have attempted to minimise the significance of the Healthcare Commission’s findings. The evidence gathered by this Inquiry means there can no longer be any excuses for denying the scale of failure. If anything, it is greater than has been revealed to date. The deficiencies at the Trust were systemic, deep-rooted and too fundamental to brush off as isolated incidents.”
The Inquiry concluded that it would be unsafe to put a figure on the number of avoidable or unnecessary deaths at the Trust. Robert Francis QC has recommended, given the lack of understanding surrounding mortality statistics and their use, that the Department of Health set up an independent working group to urgently review the gathering and use of mortality data in the NHS.
Over the course of the Inquiry, many people expressed alarm at the apparent failure of external organisations to detect any problems with the Trust’s performance. Robert Francis QC has recommended that the Department of Health commission an independent examination of these bodies in order to restore public confidence in the system.
Despite the findings of the Inquiry, Robert Francis QC has concluded that Stafford Hospital should not be closed. He believes that whilst there is still much work required at the Trust, the new Executive team has made a successful start in improving the safety and quality of care it provides. To assist the Trust in this process 15 recommendations for the Trust have been made and he has recommended that the Secretary of State for Health reviews the Trust’s status as a Foundation Trust.
Speaking in Stafford Mr Francis said: “I have been struck by the commitment of the local community to its hospital. So many people who gave evidence were motivated because they care deeply about the hospital and want to see it improve. I hope that the Trust will soon be able to regain the confidence of its local community which it will achieve, not through words, but demonstrable actions and results.”
The presentation of his report was concluded with a message for all concerned with the management of NHS hospital services that: “People must always come before numbers. Individual patients and their treatment are what really matters. Statistics, benchmarks and action plans are tools not ends in themselves. They should not come before patients and their experiences. This is what must be remembered by all those who design and implement policy for the NHS.”
In the government’s initial response to the Francis inquiry, it pledges that quality of patient care will be put at the heart of the NHS and that a culture of compassion will be a key marker of success, ending the negative impact of targets and box ticking which led to the failings at Stafford Hospital.
Radical new measures will be introduced to achieve this including Ofsted-style ratings for hospitals and care homes, a statutory duty of candour for organisations which provide care and are registered with the Care Quality Commission, and a pilot programme which will see nurses working for up to a year as a healthcare assistant as a prerequisite for receiving funding for their degree.
The response is accompanied by a statement of common purpose signed by the chairs of key organisations across the health and care system. It renews and reaffirms the commitment to the values of the NHS, as set out in its Constitution, and includes pledges to work together for patients, always treat patients and their families with compassion, dignity and respect, to listen to patients and to act on feedback.
In order to put in place a culture of zero-harm and compassionate car, the government says there will be a new regulatory model under a strong, independent Chief Inspector of Hospitals. The Chief Inspector will introduce single aggregated ratings. The Nuffield Trust rightly said that in organisations as large and complex as hospitals a single rating on its own could be misleading. The Chief Inspector therefore develop ratings of hospital performance at department level. This will mean that cancer patients will be told of the quality of cancer services, and prospective mothers the quality of maternity services. The Chief Inspector of Hospitals will also assess hospital complaints procedures.
The CQC will move to a new specialist model based on rigorous and challenging peer-review. Assessments will include judgements about hospitals’ overall performance including whether patients are listened to and treated with dignity and respect, the safety of services, responsiveness, clinical standards and governance.
A new Chief Inspector of Social Care will ensure the same rigour is applied across the health and care system. The merits of having a Chief Inspector of Primary Care are also being explored
What’s more, the NHS Confederation will review how to reduce the bureaucratic burden on frontline staff and NHS providers by a third.
DETECT PROBLEMS QUICKLY
A new set of fundamental standards will be introduced to make explicit the basic rights that anyone should expect of the NHS. They will be produced by the Chief Inspector of Hospitals, working with NICE, patients and the public. Where these standards are breached, a new failure regime will ensure that firm action is taken swiftly. If it is not, the failure regime could lead to special administration with the automatic suspension of the Board
A new statutory duty of candour will ensure honesty and transparency are the norm in every organisation overseen by the CQC.
To help detect problems quicker, the new Chief Inspector of Hospitals will be the nation’s whistleblower‑in‑chief. And as publishing survival results improves standards, as has been shown in heart surgery, survival rates for a further 10 disciplines, including cardiology, vascular and orthopaedic surgery, will now be published.
ACCOUNTABILITY FOR WRONGDOERS
Health and social care professionals will now be held more accountable. The government is considering the introduction of legal sanctions at a corporate level for providers who knowingly generate misleading information or withhold information from patients or relatives.
The General Medical Council, the Nursing and Midwifery Council and the other professional regulators have been asked to tighten and speed up their procedures for breaches of professional standards.
The Chief Inspector of Hospitals will also ensure that hospitals are meeting their existing legal obligations to ensure that unsuitable healthcare assistants are barred
LEADERSHIP AND MOTIVATION
NHS-funded student nurses will spend up to a year working on the frontline as healthcare assistants, as a prerequisite for receiving funding for their degree. This will ensure the people who become nurses have the right values and understand their role. Nurses’ skills will then be revalidated, as doctors’ are now, to ensure their skills remain up to date and fit for purpose. Healthcare support workers and adult social care workers will now have a code of conduct and minimum training standards, both of which are published at www.skillsforhealth.org.uk.
The Chief Inspector will ensure that hospitals are properly recruiting, training and supporting healthcare assistants. The Department of Health will become the first department where every civil servant will gain real and extensive experience of the frontline.
The Government is also publishing a revised NHS Constitution following a recent public consultation. It incorporates many of the changes that were consulted on and, where possible, further changes resulting from additional suggestions heard through consultation. A copy can be found on the Department of Health website.
It is likely there will be a further consultation later in the year on further changes to the NHS Constitution, with the aim of incorporating further recommendations made by Robert Francis QC.
REACTIONS FROM THE INDUSTRY
Commenting on the government’s response to Robert Francis’s report, Chris Ham, Chief Executive of The King’s Fund said: “We broadly welcome the government’s general approach. Quality of care should be a guiding principle for the NHS, and it is for the Secretary of State to make this clear. He cannot legislate for compassion but he can create a more stable environment, in which NHS organisations focus on improving quality of care.
“Effective regulation has an important role to play as a ‘backstop’ against failure, but it is only actions on the ward and board that will deliver compassionate care for patients. This will require leaders, from chief executive to frontline clinicians, to start developing a culture of care as a matter of urgency. But we recognise this is not without its challenges, especially in the current financial climate where time and resources are under pressure.
“The value of aggregated ratings for hospitals is highly questionable; these are complex organisations with different services and specialisms that may vary in quality so an overall rating can hide significant failings within a trust. We welcome the proposal for ratings for specific services, which we think will be of much greater value.”
Robert Francis QC, who chaired the public inquiry, said of the government’s response: “Even though it is clear that it does not accept all my recommendations, the government’s statement indicates its determination to make positive changes to the culture of the NHS.”