Vicky Sargent’s blogwatch 16: The Francis Report, what next

Blogger reaction to the Francis Report (download here) has been huge, no surprise when the issues raised include the NHS, care of the vulnerable, and accountability of public services.

Anna Dixon, Director of Policy at the King’s Fund discusses what needs to be done to build a culture of compassionate care within the NHS. She says ‘the report addresses at least three key issues that are essential to supporting the delivery of high-quality care: clear and robust accountability, openness and transparency, and effective regulation.’

Dixon highlights the report finding that local GPs in Stafford ‘were slow to recognise the problems in their local trust’, wonders why this was so, and what support GPs need. She also comments on the Francis proposal that in all individual cases ‘a senior clinician is identified who can take charge of a person’s care’ - something that she says is especially important for vulnerable patients and those with complex conditions.

She goes on to say that King’s Fund research ‘has found that hospitals are still not designed to care for the increasing number of these patients’ and that ‘putting an end to practices such as discharging patients in the middle of the night will also greatly improve the experience of care.’

This latter theme is echoed by Chris Moon-Willems, founder of Relative Matters, a social enterprise that supports people caring for older people. In her experience ‘poor standards of care for older people on hospital wards is endemic.’

Moon-Willems wants to know why the people responsible at Mid-Staffs are not being investigated for consideration of corporate manslaughter: ‘Whenever front line staff are accused of a transgression affecting patient care they are quite rightly subjected to disciplinary investigation. Why on earth should this be any different for the people ultimately responsible for patient care at that hospital?’ she asks.

Dr Nick Tupper, the GP chairman of NHS Doncaster CCG believes that it has been the collective impact of five factors that has ‘changed the NHS ethos and culture and sowed the seeds that allowed Mid Staffs to happen.’

Among these were turning nursing into a degree subject, making nurses ‘less focused on the act of caring for a patient’; the European Working Time Directive that resulted in the loss of medical teams, apprenticeships and sense of belonging to your ‘team’; the formation of hospital trusts – which placed an emphasis on financial viability rather than quality; and the setting of targets that focused on process and not clinical outcomes.

Tupper is not the only commentator to blame government reforms for what went wrong. The GP who blogs as The Jobbing Doctor says things started to go wrong under New Labour, which did not always spend the extra money it allocated to health wisely, and is ‘part of the problem of mid Staffordshire, and not the solution.’

In an earlier post The Jobbing Doctor singles out more specifically those he regards as responsible (but whom he clearly thinks will get off the hook). In the spirit of ‘j’accuse’ he names the Hospital board; officers of the Strategic Health Authority; people in Monitor and the Health Care Commission; officials in the Department of Health; special advisers and lobbyists; those in Parliament who promoted NHS changes; and Government Ministers.

Paul Corrigan, a former adviser on health to Tony Blair, is upfront about the fact that the Francis report is ‘a reflection on the work in which I had been involved for 6 years in Whitehall’ and open in his dissatisfaction with his own performance back then.

The particular issue he writes about is the ‘closed nature of much of NHS culture’ which is picked up by Francis as the one of the main problems that needs changing. ‘All of the warning signs were missed’ he says,  ‘because they were reviewed again and again by people inside the culture.’

Corrigan is prepared to shoulder at least part of the blame for the fact that, having been introduced in 2001 against much resistance from within the sector, a hospital ratings scheme was later dropped. As he puts it: ‘the closed culture of the NHS won a battle to say that their organisations are too complex to be categorised in a simple way that the public can understand.’

The need to open up the NHS more effectively to public scrutiny is picked up in other blogs. Michael Harris, writing in the Guerilla Policy blog believes that it is ‘vital that we strengthen the public’s and patients’ ability to challenge the system from the outside.’

It's a puzzle, they say, why there wasn’t more public alarm about what was happening: ‘of course there was, but complaints and concerns were regularly ignored or dismissed’. And, they say, institutions and systems have ‘an inevitable tendency to defend themselves and deflect criticism – or often to co-opt critics and turn them into insiders……. we can never rely on institutions to improve themselves or be regulated into improvement, especially when the required changes concern caring and the quality of human relationships.’ Developments like Patient Opinion are encouraging, because they show the possibilities for the internet and social media to hold institutions to account from the outside.

Others are sceptical about greater regulation on its own being the answer. Writing in the Institute of Government blog, Nicholas Timmins, until recently public policy editor at the FT, says the risk is that Francis will result in ‘more bureaucracy, an army of inspectors whose existence will offer false comfort’ and the creation of ‘unmanageable organisations in a revamped Care Quality Commission and revamped NICE.’ This will simply create ‘a culture more of fear and caution than one of openness and innovation, a reluctance among lay people to take on the role of non-executive directors on boards in the face of new criminal sanctions, and a health system that ossifies.’

‘The awkward truth’ he says, ‘is that we still don’t really know how to inspect hospitals.’ Hospitals are complex, and finding the right mix of analysis and inspection has so far proved elusive: not even in Mid-Staffs was everything awful. What is far more likely to work, he says, is ‘taking complaints seriously, GPs listening to the feedback from their patients and acting on it, staff working in a culture that cares and is open.’ The duty of candour and publication of more information could be really helpful and far more effective than more inspection.

Finally, a word from someone whose job it is to keep all a hospital’s plates on sticks, including patient safety. Dr Mark Newbold is Chief Executive of Heart of England NHS Foundation Trust, and is responsible for running three hospitals (including my own ‘local’) and a range of community services.

In his post ‘Why do we struggle with ‘caring’ in the NHS’ he cites three contributory factors. Two of these, the rise of managerialism and targets and performance culture have been well discussed elsewhere. The third is the growing pressure on hospitals, which is less well recognised, at least by those in power.

‘With shorter lengths of stay, a higher proportion of patients are very ill, requiring more intensive care and support’ he says. And, while designed to provide acute care, hospitals are now ‘the default option’ for the entire system, because while all other providers close at times, hospitals are always open, even when full.

Alongside this sits a relentless push to reduce capacity, even though there has so far been no ramping up of alternative means of supporting people elsewhere, ‘since the entire system of care has not kept pace with changing demography.’ Dr Newbold promises to set out some solutions in his next blogpost.

As we try to digest the Francis Report news is emerging of digital ways to ensure that capturing, communicating and understanding the reality of the "patient experience" becomes an integral part of the healthcare landscape. On Tuesday March 5th The Information Daily will publish a package of exclusive written and video content Towards A Digitally Enabled Health Service

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