Mid Staffordshire public inquiry: an overview

Author: Nicola Green, Capsticks

The final Francis report into failings at Mid Staffordshire NHS Foundation Trust has been published. The report, which makes 290 recommendations, is critical of the culture at the trust.

Robert Francis QC was initially commissioned by the Department of Health in 2009 to undertake an independent inquiry into the high number of deaths that occurred at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. The first Francis report, published in 2010, found that the trust failed to deliver acceptable standards of care to many of its patients over a sustained period of time.

Following the publication of the first report, Francis was commissioned to chair a public inquiry into the operation of the commissioning, supervisory and regulatory organisations and their monitoring role of Mid Staffordshire between 2005 and 2009.

The final Francis report was published on 6 February 2013. It found that, in focusing on financial stability and attaining foundation trust status, the trust's board had lost sight of its main priority: to put the patient first. Further, it found that, the trust had failed to listen to the complaints that it received from patients, relatives and staff and, as a result, serious problems were neither identified nor acted upon.

In his final report, Francis makes recommendations to improve NHS care and avoid a reoccurrence of the tragic events that took place at Mid Staffordshire. The recommendations can be split into a number of categories.

Governance and trust boards

Francis recommends that there is a cultural change in the NHS to ensure enhanced accountability at board level. He recommends that this is achieved through:

  • training and continuing development of directors;
  • introducing a code of conduct for directors; and
  • introducing a fit-and-proper-purpose test and robust processes, so that those who do not pass the test can be removed and in certain cases disqualified from acting as a director in the future.

Regulation

Francis recommends that there is:

  • a single regulator dealing with authorisation, corporate governance, financial competence, viability, safety and quality standards, and that this regulator is the Care Quality Commission;
  • a hierarchical system of standards, to ensure patient safety and a zero-tolerance approach to substandard care;
  • a new role for national regulators such as the Nursing and Midwifery Council and the General Medical Council, and that these regulators produce clear guidance on when concerns should be reported to these bodies, thereby ensuring that the systems of training and education of the medical and nursing profession maintain their first priority of patient safety; and
  • a standardised code of conduct for healthcare assistants, as well as standards for education and training.

Information

Francis noted that many external organisations had concerns about Mid Staffordshire, but did not act upon them. For example, local GPs who had concerns raised these only with individual consultants. Francis highlights the importance of the regulator, commissioners and patients having access to a broad range of shared information.

Workforce issues

Francis calls for a more rigorous approach to the management of difficult personnel issues by the NHS. This includes giving contractual force to duties around NHS values and the NHS Constitution, and requiring senior managers to comply with a code of conduct and standards. The report also recommends that fitness-to-practise procedures should not delay actions of providers and suggests that employment disciplinary proceedings may need to be reviewed to enable this.

Overall, the message from the report is clear: the proper care and treatment of patients must be a priority.

The Government response

The Government published a response to the report on 26 March 2013. It sets out that certain steps will be taken.

  • New ratings for hospitals and care homes, to be overseen by an Independent Chief Inspector of Hospitals and Chief Inspector of Social Care, with patient experience at the core of an aggregated rating system.
  • Where breaches of fundamental care are identified, a new three-stage process with time limits will be introduced to rectify the breach. If a trust fails to rectify a breach, it will be put into the "failure regime". This marks a significant move: it is not only economically unsustainable providers that could be put into the failure regime, but also poor clinical providers.
  • A statutory duty of candour for organisations that provide care and are registered with the Care Quality Commission (although not extending to individuals, which was recommended in the Francis report).
  • The Care Quality Commission will refer criminally negligent practice in hospitals to the Health and Safety Executive.
  • The Care Quality Commission will no longer be responsible for putting right any problems identified in hospitals: its enforcement powers will be delegated to Monitor and the Trust Development Authority, whom the Care Quality Commission will be able to ask to act when necessary.
  • A review by the NHS Confederation on how to reduce the bureaucratic burden on frontline staff and NHS providers by a third. The Government has taken the view that too much information is generated, but too little "intelligence".
  • New nurses will need to undertake training on the front line and new standards will apply to healthcare support workers.
  • A revised NHS Constitution has been published to reflect that the NHS's most important value is for patients to be at the heart of everything it does.
  • Nine other recommendations relate specifically to the NHS Constitution and the Government is considering these further.

What should NHS employers do now?

While many of the recommendations in the Francis report will require new legislation, the first recommendation is that all healthcare bodies immediately evaluate their own organisation against the report's findings and recommendations, and continue to do so in the future. All NHS hospitals are expected to set out how they intend to respond to the report before the end of 2013. In particular, trusts should consider:

  • how far the organisation goes at all levels to support a positive, patient-centred, safety and quality culture across the services they commission or provide, with openness, honesty and candour inbuilt and applied within the organisational systems and processes;
  • whether or not the organisation allows a cultural tolerance of poor practice and continuing safety issues to operate;
  • whether or not the information that the organisation produces or interprets accurately reflects what is happening "on the ground"; and
  • whether or not the board leads on improving quality across the organisation and the patient experience.

Future developments

Further consideration and consultation is needed on a number of the recommendations that have been made in the report and certain organisations have been charged with reviewing their processes and delivering the recommendations set out in the Francis report. The Government hopes that one of the worst episodes in the NHS can be seen as a watershed moment and turned into something positive, and, that the NHS will be a health and care system that puts patients first, and treats people with dignity, respect and compassion.

The Francis Report Read the Francis Report on the Mid Staffordshire NHS Foundation Trust Public Inquiry website.
Patients First and Foremost: The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry Read the Government Response to the Francis Report on the Department of Health website.
The Francis Inquiry Read about the Francis Inquiry on the NHS Employers website.
The NHS Constitution is on the NHS Employers website.