The Francis Report: Add Benefit, Not Just Bureaucracy

7 February 2013

The Francis Report: Add Benefit, Not Just Bureaucracy

Exactly 290 recommendations spanning four volumes and 1,782 pages comprise the core of Robert Francis’s report on the chronic failings at the Mid Staffordshire NHS Trust and which now unfortunately buttress the very fabric of the NHS itself. It is a salient and guileless report which remains firmly rooted in addressing the decidedly swift erosion of the founding culture of the NHS since its inception and the fact that both accountability and responsibility therein were spurned in favour of expedience, a race to the top of the proverbial government cash flow mountain (or bottom as it would so transpire) and in ensuring that image and reputation prevailed at any cost over the rudiments of compassion, decency and in putting the patients’ rights, feelings and health first.

The failings were numerous, severe and embedded, and the cost of them - in quality of care, in suffering and lives, in trust - is something that needs to be fully investigated and understood. However whilst the organisations that failed to discharge their duty and responsibility to patients were numerous, the restructuring and radical reorganisation now required cannot be mired in prolonged bureaucracy, chains of command that interweave with elaborate complexity and money thrown at the NHS for the sake of quieting the very voices that raised in unison to throw a spotlight on the Mid Staffordshire NHS Trust in the first instance.

Let us now address some of the proposed changes highlighted in the report, notwithstanding the most fundamental-a literal heart transplant for the NHS itself as an institution-one which adumbrates a culture of care, empathy and genuine concern for the patient above management objectives, tick lists and an over arcing desire to claim the prized status as a Foundation Hospital.

Nurses to be held personally and criminally accountable for the care that they provide to their patients:

Buttressing the most basic requirement to care for patients, this proposed reformation was highlighted by the stark realities of wanton disregard for the very individuals nurses and healthcare assistants were responsible for. Whether it was the failure to feed patients who were unable to do so themselves, ignoring repeated requests for help when reaching for drinks of water left out of reach, prescribed medicines which were failed to be administered, early discharges without attempting to assuage the condition of the patient before leaving the hospital premises and the reprehensible finding that an unacceptable number of patients were left in filthy urine and excrement-soiled bed clothes, the impunity with which this behaviour progressed must be tackled head on with civil and criminal charges.

Hospital boards should face dismissal if they fail to ensure minimum standards of safety and quality care

Precluding the fact that levels of common human decency should have been upheld at all stages, the report focused on a fundamental failure in addressing faults and areas rife for improvement within the hierarchy of Stafford Hospital itself. These were compounded by a ‘pass the buck’ mentality which was interposed by the deceptive practice of clouding errors, mistakes, incidents where care fell far below the requisite level expected and the equally disturbing practice of dressing up (or in some cases disregarding) patient complaints so that they appeared to be less forceful, worrisome and significant than they in fact were.

Patient groups should be properly funded with training given to members and the ability to carry out inspections of wards as well as the ability to bring in outside experts.

Lest it be forgotten, it was the voices of those who suffered at the hands of the neglect of individual nurses, healthcare assistants and the red tape of management determined to preserve the deluded sheen of excellent service that raised the alarm at Stafford Hospital as well as the united cry of their families who demanded change. With no lobby groups to satisfy, funding objectives to reach and funding milestones to cross, grouped organisations such as, for instance,  the Public and Patient Involvement Forum at Stafford did the very best they could despite the fact that it relied on uninformed and untrained volunteers. Giving organisations such as these the funding, restructuring and support is an important recommendation so that the alarm can be raised again if need be at individual hospitals in the future without reproach or stigmatisation .

 Greater responsibility for GPs

Highlighting the fact that the systematic failures identified by Francis were not isolated to Stafford Hospital, the failing culture of NHS care and bureaucracy in general; GPs should also monitor all hospitals where they send their patients including carrying out professionally qualified checks on the quality of service offered as well monitoring outcomes.  This designates that the chain of neglect does not necessarily originate within the hospital premises itself, but also in the fact that the GP’s duty does not end after the referral stage but is rather prevalent throughout the entire lifespan of care for the patient in question.

A unit of hospital inspectors created with the involvement of patients to signpost problems at the earliest opportunity

Whether it was the Healthcare Commission or the CQC unsuccessfully interweaving their duties during the Stafford Hospital scandal and failing to expedite solutions to concerns raised, the report highlights the need to instigate a focused unit of hospital inspectors who can assess and report on standards of patient care across the NHS properly-that is in having the requisite funding to discharge this responsibility and in carrying out relevant inspections; relevant being the operative word as those limited inspections which the CQC did undertake, lacked the most prescient features, that is if the CQC inspected a nursing ward, a nurse was not brought along with the inspecting team so as to provide their own highly relevant insight.

Closer synchronisation and erosion of a ‘top down’ restructuring of the NHS

A corollary of the above recommendation, this adjustment also rebuts the presumption that management is in close synchronisation with the front line of nurses and healthcare assistants in hospitals when the reality is very different. This recommendation then ensures that both the right and left hand know exactly what they are doing at all stages. Henceforth, at all times there should be senior clinical involvement in policy decisions and all staff should spend time on the frontline as well as meeting those who have suffered bad experiences. Notwithstanding the fact that a greater amelioration in understanding is gained by those at the top of the hierarchical structure, management can then not shirk or sidestep its responsibility when the true face of neglect, haphazard practices and slip shop nursing and care delivery stares them in the face.

It is the overriding objective of this report that the NHS culture should reflect care and compassion, enabling and supporting staff to deliver at an individual level. It should also promote opportunities for an open and honest discussion of areas that could be improved, creating a forum to listen to staff, patients and their families.

Unfortunately the report is the tip of the iceberg, merely highlighting a truly reprehensible set of circumstances which arose and then were prolonged at the Stafford Hospital. There are still many voices that have not yet been heard and practices at hospitals which remain mired in complacency, wishful thinking, box ticking and outright denial. Law suits are spurned from these practices which are numerous and sometimes neglect is only identified when it is too late.

Mr Priyesh Bhardwaj is an experienced medical negligence claims adviser within the specialised arena of clinical negligence and works diligently with the experienced team at mistreatment.com; his vast case load has more often than not encompassed care home neglect and the kind of abandonment of patient care which has typified the findings of this damning report. Commenting on its findings, Mr Bhardwaj opined that :

‘The findings of the Francis Report have surfaced concerns of patient’s that I have personally dealt with on a regular basis and on numerous occasions. I feel a sense of relief that the patients voices that I have listened to and advised, are now being heard  by an individual in power to enforce the changes we have required for many years. I can recall many patients who are not in a position to care for themselves, whether that be due to a terminal illness or disability, are placed into the hands of the NHS with complete trust, however they fail to receive the care and attention due to their condition. This may be as basic as failing to provide the nutrition, sanitation and hydration required, or as distressing as failing to provide the necessary medication and pain relief. ‘

Mr Sibtain Lakha is a Clinical Negligence Claims Director overseeing the cases Mr Bhardwaj leads and also feels that:

It seems the very essence of the word ‘care’ is being misunderstood by the very professionals that provide it.  Whether an establishment is a corporate provider funded through a higher level of acuity through private payees, or those members of the public more reliant upon the public purse, those that are meeting or, rather modelling their professional responsibilities, seem at paucity. 

Personally, I cannot see any improvement in the short-term, not unless, there is a comprehensive review on operational performance and standards, to understand exactly how and why the delivery of care is being compromised at such deplorable levels. What else will it take before the regulators decide to implement a more robust and overhauled standard of monitoring establishments providing patient care? And why is it becoming all too common that the public and those directly affected, have to wait until the publishing of damning reports, or, whistle-blowers who have witnessed too much, before the media congregate whilst rubbing their hands at having something to fill their papers with for at least a fortnight. Local authorities need to become more full-bodied in their stance at exercising the option to close poor quality units, and brandishing hefty financial penalties to those that breach the foundation of their responsibilities.

It’s a shame that a disparity in understanding starting at the very top of the tree, has led to people with physical disabilities, the elderly under dementia care, or even, palliative care patients, being failed on the very basis that the component of care is paid mere lip service for purposes of industry sector recognition, without understanding the core purpose of their care facilities."

Mistreatment.com is an organisation that can put patients and their families in touch with specialists in healthcare and patient rights advice who deal specifically with  the kind of mistreatment, neglect and lack of care that the report highlighted. If you would like advice, support and guidance about your rights regarding any experience you or a loved one has experienced under the NHS, Mistreatment.com is able to provide you with that help.