The Mid-Staffordshire case was one which led to an inquiry and the Francis Report into how negligent conditions were able to persevere over an extended period of time.
The report looked at the period between 2005-2008 in which “conditions of appalling care were able to flourish in the main hospital serving the people of Stafford.” During this time the hospital was managed by a board which even managed to help gain the hospital foundation trust status.
During the time the hospital was being assessed for foundation status which it was eventually approved for despite the “appalling care” and despite thorough assessments as part of their application process. The following missed opportunities to identify and report the poor standard of care:
The Strategic Health Authority (SHA) and Department of Health (DH) which had assessed the hospital.
The Healthcare Commission (HCC) which had stated that the hospital had, for the most part, been compliant with the set standards.
The NHS Litigation Authority had also rated the hospital for its risk management procedures.
In the end the truth was uncovered by:
Attention being paid to the true implications of its mortality rate.
Persistent complaints by a group of patients.
Following the initial report the Secretary of State for Health called an inquiry under the Inquiries Act 2005. This was to look into the failure:
“So why another inquiry? We know only too well every harrowing detail of what happened at Mid Staffordshire and the failings of the trust, but we are still little closer to understanding how that was allowed to happen by the wider system. The families of those patients who suffered so dreadfully deserve to know, and so too does every NHS patient in this country.
This was a failure of the trust first and foremost, but it was also a national failure of the regulatory and supervisory system, which should have secured the quality and safety of patient care. Why did it have to take a determined group of families to expose those failings and campaign tirelessly for answers?”
Outcome:
The Francis Report recommended:
“In response, and to support all NHS organisations to learn from and respond to the recommendations of the report, the DH published three reports designed to help embed effective governance and detect and prevent such serious failures occurring again:
Review of Early Warning Systems in the NHS, which described the systems and processes, and values and behaviours which make up a system for the early detection and prevention of serious failures in the NHS
Assuring the Quality of Senior NHS Managers, which set out recommendations to further raise the standards of senior NHS managers;
The Healthy NHS Board, which set out guiding principles to allow NHS board members to understand the collective role of the board and individual role of board members, governance within the wider NHS and approaches that are most likely to improve board effectiveness.”
The Royal College of General Practitioners summarised the government's response:
The Government has made the following commitments in their response:
Preventing problems
Following the Fundamental Review of Data by the NHS Confederation, a drive to reduce paperwork and a focus on outcomes rather than processes will be implemented to give NHS staff more time to care.
Professor Don Berwick (former adviser to President Obama) will lead a National Patient Safety Advisory Group to advise on a whole system approach to ensure ‘safety and a zero tolerance of avoidable harm is embedded in the NHS’. The report is due in July 2013 and will advise on how to bring about genuine cultural change.
Appointment of Inspectors - The Care Quality Commission will appoint a new Chief Inspector of Hospitals and a Chief Inspector for Social Care to champion the interests of patients and make judgements about the quality of care. The Government has also said it will also look into the merits of a chief inspector of primary care (see Section B).
The role of CQC will widen from being a regulator of compliance to becoming an inspector of quality. Monitor and the CQC will remain separate organisations .
Detecting problems quickly
An aggregated rating system for healthcare providers (possibly including GPs) similar to ‘OFSTED style’ ratings will be introduced. No hospital will be rated as good or outstanding "if fundamental standards are breached". (See Part B for an overview of the GP specific recommendation).
A Duty of Candour will be introduced applying to providers to reinforce the existing contractual duty. It appears unlikely that this will be extended to individuals although this has not been clarified beyond doubt.
Taking action promptly
Fundamental standards below which care should never fall will be developed with the CQC, NICE, commissioners, professionals, patients and the public.
Following the Law Commission’s review of the legal framework for professional regulation there will be an overhaul of the complex legislation in this area into a single Act to enable faster and more proactive action on individual professional failings. The GMC, Nursing Midwifery Council and other professional regulators will consider the Law Commission’s recommendations further before making a fuller response.
Ensuring robust accountability
A barring mechanism will be introduced to prevent unsuitable executives from moving to senior positions elsewhere.
Ensuring staff are trained and motivated
Student nurses will spend up to a year on the front line working as healthcare assistants. This will become a prerequisite of obtaining funding.
Revalidation for nurses – Chief Nursing Officer and the Department of Health Director for Nursing will work with the Nursing and Midwifery Council in developing an effective and affordable approach to revalidation appropriate and proportionate to nursing and midwifery professions.
The Chief Inspector of Hospitals will ensure that all hospitals are acting upon the recommendation that all healthcare assistants are properly trained and inducted before they care for people. The new Chief Inspector for Social Care will also ensure that all unregulated social care support staff have the induction and training they need to meet their employers’ registration requirements.
The Government take action to attract professional and external leaders to senior management roles. They will extend the NHS Leadership Academy’s development programmes for a range of NHS staff including doctors, allied health professionals, nurses, midwives, pharmacists and healthcare scientists, to help them in leading their teams, services and organisations to achieve better, more compassionate patient care.
Within four years, every civil servant in the Department of Health will have experience of the frontline with the Senior Civil Service and Ministers leading the way.
You can find the complete executive summary below:
You can also find the video of Mr. Robert Francis QC presenting his findings: