News / News analysis: After Francis

The findings of the second Francis report in February were not unexpected, yet they sent shockwaves through the NHS and the
wider public. In its wake came expressions of regret and calls to action from politicians, NHS staff and patients. The government’s initial response came in March and in November a further line-by-line reply to Francis’ 290 recommendations promised to usher in a new era.

Changes have already been made. Care Quality Commission inspections have been beefed up and new national inspectors appointed for hospitals, primary care and social care. The Keogh review of the 14 hospitals with the highest mortality rates led to 11 being placed in special measures, while an inquiry led by US health specialist Don Berwick sought to identify how the NHS could make zero harm a reality. The government is also legislating for a new failure regime that looks at quality and finance.

November’s full response – Hard truths: the journey to putting patients first – accepted 204 recommendations in full, as well as 57 in principle and 20 in part. Nine recommendations were rejected. It examines the measures in five areas:

• Preventing problems, including instilling greater openness in the NHS
• Early detection of problems
• Prompt action
• Robust accountability
• Ensuring staff are trained and motivated.

The NHS has a reputation for being a secretive service in terms of the amount of clinical and financial data it makes available. But the Department of Health wants it to be more accountable, safe and open – themes that run throughout the response.

For example, the report said staffing at ward level – often a patient concern – will be published by June 2014 at the latest. Trusts will have to report the percentage of shifts where staffing requirements were met. Actual and planned nursing and midwife levels will be published each month and trust boards must review this information every six months. This will be monitored by the CQC.

The National Quality Board and chief nursing officer will set out current evidence on safe staffing and the National Institute for Health and Care Excellence will follow this with independent guidance on safe staffing by summer 2014. The Department said hospitals were planning to hire more than 3,700 extra nurses in the coming months.

Safety website

From June 2014, a new website on hospital safety will offer details on indicators such as staffing, pressure ulcers and healthcare-acquired infections. Health professionals and providers will have a duty of candour when mistakes occur – for individuals this will be delivered through changes to their professional body guidance and codes of practice.

A failure to meet the duty of candour could lead to a financial penalty for trusts. The Department said it would consult on a measure that would require trusts that have not been open about a safety incident to reimburse some or all of the amount paid by the NHS Litigation Authority (NHSLA) in compensation. While the NHSLA would continue to pay successful claims in full, it would have the discretion to shift the financial liability to the trust.

NHSLA chair Dame Joan Higgins welcomed the move. ‘Patient and staff safety is a top priority for the NHSLA, with a goal of supporting the NHS to reduce harm through learning from our claims. The NHSLA is providing timely information to members to help them to do this,’ she said.

‘We have always worked with our members to help them and the NHS to be open and transparent with patients and their families when things go wrong. The NHSLA therefore supports the proposal to undertake a consultation in relation to the duty of candour.’

Other measures include:

• A new national patient safety programme
• The appointment of 5,000 patient safety fellows, who will be trained and appointed by NHS England within five years
• Quarterly complaints reporting and better complaints information
• A new criminal offence of wilful neglect.

The report said the latter would hold to account organisations and staff responsible for the worst failures in care, be they managers or clinicians.

Senior managers could be barred from taking NHS jobs by the CQC under a new fit and proper person’s test. A care certificate will be introduced for healthcare assistants and social care support workers. Unsuitable staff will be prevented from being re-employed elsewhere. The NHS Confederation has undertaken a review of the bureaucratic burden on the service and there is a commitment from the Department and all arm’s-length bodies to minimise the bureaucratic demands on trusts.

Progress on the report as a whole will be reported to Parliament each year. Health secretary Jeremy Hunt said the measures were ‘a blueprint for restoring trust in the NHS, reinforcing professional pride in NHS frontline staff and above all giving confidence to patients’. He continued: ‘I want every patient in every hospital to have confidence that they will be given the best and safest care and the way to do that is to be completely open and transparent.

‘I do not simply want to prevent another Mid Staffs. I want our NHS to be a beacon across the world not just for its equity, but its excellence. I want it to offer the safest, most compassionate and most effective care available anywhere – and I believe it can.’

Hard truths was broadly backed. The HFMA said in a statement: ‘The HFMA welcomes the government commitment to openness and candour. In the association response to the Francis report, we called on finance professionals to make a personal commitment to openness, candour, transparency and collaboration. They should aim for the highest standards of financial probity and financial reporting and, with an understanding of the services delivered, promote the best use of resources and the achievement of value for money. However, while chief finance officers have a particular focus on financial performance, all governing board members must share responsibility for quality, safety and finance.'

NHS Confederation director of policy Johnny Marshall also welcomed the government response, backing the move on the duty of candour. He also supported the indemnity cover proposal in principle. ‘We will need to look closely at the details to ensure that the process is fair and there are no unintended consequences,’ he said.

And, while the publication of staffing levels would ensure greater transparency, he warned: ‘Crude national ratios around nursing numbers risk hitting the target but missing the point. It would be possible for wards with seriously ill patients to meet the ratio while having insufficient or the wrong mix of staff to actually meet patient needs. We therefore support the local flexibility to have the right people, in the right place, at the right time.’

While also welcoming the report, King’s Fund assistant director of policy Catherine Foot said the changes would take place against a backdrop of severe financial pressure.

Foundation Trust Network chief executive Chris Hopson said: ‘Patient safety and quality of care will always be the guiding principles of NHS providers. But those providers are facing ever-increasing demands that need to be delivered on ever-decreasing real budgets. While instances of quality failure will never be acceptable, the NHS also needs a much more honest debate about what improvements can be made and how quickly, given the unprecedented financial squeeze the service is facing.’

Mr Hopson backed the government decision to avoid mandatory minimum staffing levels, but added that the additional reporting requirements must not divert resources from the front line.

Resources will be important, but so too will a change in culture. After Francis, the message is that all staff are responsible for delivering safe, effective, compassionate care to patients. Few would argue against that. 

An HFMA summary of the government's full response to the Francis report is available from here.