Measuring the Francis effect on the NHS

As we approach a year since the government published Hard Truths – its response to the report of the Mid Staffordshire Public Inquiry, chaired by Robert Francis QC – it is important to ask, what has been the ‘Francis Effect’ on the NHS? This isn’t an easy question to answer. First, it is difficult to attribute improvements directly to the Inquiry, particularly given the constantly shifting landscape of patient safety policy in England. Second, any impact could be part of a secular trend; we must remember that the Healthcare Commission first published its shocking findings of what happened at Mid Staffordshire back in 2009. And third, if there has been an effect, what has been the benefit to patients and unintended consequences to the NHS?

A tale of two inquiries
When faced with the scandal at Mid Staffordshire, the government responded in a familiar way – it set up an inquiry. The first inquiry, which reported in 2010, told us in stark detail what happened to patients – family members having to intervene to maintain their relatives’ hygiene, patients being left in soiled sheets, and even a lack of food and water in some cases. But the report left one key question unanswered: how could this be allowed to happen? Under considerable pressure from local campaign groups and the public, the Government finally announced a public inquiry in 2010.
The public inquiry focused on ‘the role of the commissioning, supervisory and regulatory bodies in the monitoring’ of the trust – although many of these bodies had ceased to exist by the time the report was published. Perhaps the greatest challenge the Inquiry team faced was how could an investigation of the structural and regulatory landscape hope to address the deficiencies in culture and behaviour that lay at the heart of what happened at Mid Staffordshire?

The government’s response
The Inquiry’s final report made 290 recommendations, directed at the government, national agencies and regulators, service commissioners and NHS care providers. But the single underlying aim was clear, as Stephen Dorrell, Chair of the Health Select Committee, noted: “Robert Francis made 290 recommendations in his report, but in truth they boil down to just one – that the culture of ‘doing the system’s business’ is pervasive in parts of the NHS and has to change.”

In response, the government wielded every tool at its disposal – new laws, new initiatives and new reviews – in the hope of addressing the issue of culture. Actions included the following points.
The Secretary of State has made patient safety a personal priority, with NHS organisations being asked to ‘Sign up to Safety’ to reduce avoidable harm by half and save 6,000 lives. Initiatives running alongside this campaign include a Patient Safety Collaborative Programme and a range of new patient safety measures published at trust and ward level on the NHS Choices website.

A tougher approach
NHS England Medical Director, Sir Bruce Keogh, investigated 14 NHS trusts that had been persistent outliers on mortality indicators. Eleven of the 14 trusts were subsequently placed into special measures. A number of further reviews were commissioned by the government, including Don Berwick’s Review of Patient Safety in England and the Ann Clwyd/Tricia Hart Review of the NHS Hospital Complaints System.
Regulators toughened their approach to inspection and reduced tolerance for poor performance. The Care Quality Commission (CQC) took 73 enforcement actions at NHS organisations in 2013/14, compared with 21 in the previous year. Monitor more than doubled the number of interventions at NHS foundation trusts in the first 10 months of 2013-14 (21) compared to the previous year (9).
The government introduced new offences for: organisations that aren’t candid with patients about their care; organisations that provide false or misleading information to regulators or commissioners; and individuals found guilty of ill-treating or wilfully neglecting their patients.
In February 2014, the government announced that an extra 2,400 hospital nurses were hired since the publication of the Francis report, with over 3,300 more nurses working on hospital wards and 6,000 more clinical staff overall since May 2010.

Costs & unintended consequences
The cost of the public inquiry was £13.7 million, in addition to the costs of the previous independent inquiry. The Foundation Trust Network estimated that, post-Francis, the total amount that NHS foundation trusts and trusts have invested (or will invest) in care improvements in 2013/14 and 2014/15 is £1.2 billion, at least 90 per cent of which is in extra staff and recruitment. Professor Mary Dixon-Woods, member of the Berwick Advisory Group, told the Health Foundation that: “I think the most progress has been made in recognising staffing levels as a safety issue, though I don’t see any sensible consideration at the policy level of how this will be funded.”
We do not yet know the implications of the new laws introduced by the government, although the impact assessment that accompanied the regulations on ill treatment and wilful neglect estimated that there may be 240 prosecutions per year. What might this figure – equivalent to one member of staff in every trust – do to staff morale and public confidence in an already fragile health service? The criticism that the NHS received in the wake of the Mid Staffordshire scandal seems to have impacted negatively on the spirit of staff, with The King’s Fund reporting that low staff morale is now the number one concern of finance directors.
An early evaluation of the CQC’s new inspection regime suggests that it is seen as ‘transformative in comparison to the forms of regulation it replaces’, but there are concerns about its ‘cost, pace and timing’. Inspectors are carrying out between 90-320 days of fieldwork per inspection, which has clear resource implications both for the CQC and the organisation being inspected. And in the Nuffield Trust One Year On report, which explored acute hospital trusts’ response to the Francis Inquiry, trusts surveyed reported greater pressure from external bodies seeking assurance.

Back to the question of culture
However, there remains an unanswered question about whether the culture of the NHS is beginning to change. NHS England cited data released by the National Reporting and Learning System (NRLS) showing that between April and September 2013, the number of incidents reported increased 8.9 per cent on the previous year – a positive indicator for safety reporting culture. However, further analysis of the data reveals that the rate of increase in the five preceding years (using the same data periods) was actually 12.5 per cent, so the rate of increase is now slowing.

At the Health Foundation, we have heard anecdotal stories about how the culture of parts of the NHS might have changed. For instance, one district nurse told us that the concerns he now raises about staffing levels are taken far more seriously by managers. We have also funded a number of projects which have used safety culture assessment tools to measure the impact of an intervention on staff perceptions of safety, as well as providing a unique opportunity to open up conversations around safety issues.
One of the greatest challenges, and opportunities, for organisations to build a positive safety culture has emerged out of our flagship safety improvement programme, Safer Clinical Systems. We funded eight clinical teams to test the concept of a ‘safety case’ – common in other safety critical industries – to make the argument for the level of safety they have achieved following a period of diagnosis and intervention. However, it became clear that to successfully adopt the idea, the NHS will need a culture shift: from a health service that performance manages risk to one that is open and transparent about risk and proactively seeks it out.
So, if we accept this culture shift is what is required, what might the new culture look like at different levels of the health service? It would be where boards of NHS organisations have a genuine appetite to hear and take responsibility for the risks in their services. It would also be a culture where the government and regulators respond constructively to NHS organisations that are taking steps to address the risks they have identified in their own services. It would be where health professionals feel able to surface, address and, where necessary, report the risks in their services. Finally, it would be a culture where the public is willing and supported to play an active role in their care, including asking what action staff are taking to mitigate any risks.

There can be little doubting the seriousness with which the government took the events at Mid Staffordshire, the scale of the response from regulators and national agencies, and the profile that safety now has on the agendas of trust boards. What is less clear at this early stage is the direct impact that the actions taken have had on staff and patients, and whether the implementation of the recommendations has come at the expense of other quality improvement activities.

Finally, there is a nagging question about the suitability of legally-run public inquiries to explore issues around culture and behaviour, and the limitations of the blunt instruments at the disposal of government to address them.

Further information