Major clinical problems had emerged five years previously at the Mid Staffordshire NHS Foundation Trust and in 2009, the secretary of state asked Robert Francis QC to examine the cause of the failures at a system level. The final Mid Staffordshire NHS Foundation Trust public inquiry report (the ‘Francis report’) was published in February 2013 and examined the causes of the failures at the Mid Staffordshire NHS foundation trust at a system level. The inquiry concluded that the system should have picked up and dealt with the failures at the trust.
Francis highlighted that various warning signs relating to deteriorating quality had not been picked up by the wider system and suggested that the trust had prioritised financial considerations over quality considerations in the quest to become a foundation trust. Francis cited the following reasons as to why those signals had not been identified:
- there was a culture which focused on the system’s business and not that of patients
- an institutional culture which ascribed more weight to positive information rather than surveillance
- methods of measuring compliance which did not focus on the effect of a service on patients
- too great a degree of tolerance of poor standards
- communication failures between agencies and assumptions that others were taking responsibility
- a failure to appreciate the risks associated with the loss of corporate memory following repeated multi-level reorganisations.
The regulatory system
Between 2005 and 2008 poor care flourished in the main hospital serving the people of Stafford. During this time Mid Staffordshire General Hospital NHS Trust was able to achieve foundation trust status. During the authorisation process, the trust had been scrutinised by the local strategic health authority, the Department of Health and Monitor. The healthcare commission launched a special investigation due to concerns about the trust. Monitor was unaware of the concerns until after the trust had been authorised as a foundation trust and the healthcare commission was unaware at a national level that a foundation trust authorisation process was pending.
‘Healthcare is not an activity short of systems intended to maintain and improve standards, regulate the conduct of staff, and report and scrutinise performance. Continuous efforts have been made to refine and improve the way these work. Yet none of them, from local groups to the national regulators, from local councillors to the secretary of state, appreciated the scale of the deficiencies at Stafford and, therefore, over a period of years did anything effective to stop them.’
However, Francis noted that the quality failings that subsequently came to light were not attributable to the trust’s status as a foundation trust and even if Monitor had refused to authorise the trust, the deficiencies of care would most likely have still occurred.
The report was fairly critical of the Healthcare Commission’s failure to identify the warning signs of poor care earlier, but noted that it was the commission that ultimately launched a thorough investigation. Francis suggested that the annual health check and its reliance on self-reporting had not been an effective tool for identifying failure, while noting that the period under review coincided with a system of transition. The Healthcare Commission was an advance on what had gone before, but was having to cope with its abolition in parallel with the development of new concepts and tools.
While the Care Quality Commission (CQC) had not been in existence during the time of the inquiry period, it came in for some heavy criticism in the report. Francis noted the challenges of trying to merge three separate organisations while setting up a new system of registration, developing new standards and breaking into new sectors within a short timeframe. Francis suggested that the evidence received by the inquiry indicated that CQC was not a happy environment to work in and that there had been evidence of a ‘defensive, institutional instinct to attack those who criticise it’.
The inquiry report suggested that the responsibilities and accountabilities of external agencies were not well defined, which often resulted in regulatory gaps and siloed working. This situation had been exacerbated by the constant reorganisation of NHS structures, which often led to a loss of corporate memory and misunderstandings about an organisation’s functions and responsibilities.
Francis made 290 recommendations based around the following themes:
- introducing fundamental care standards
- a requirement for openness, transparency and candour across the system
- public access to accurate information to allow people to compare services and providers
- stronger patient involvement
- a shift in culture of staff and management in the organisation to one that was supportive and based on transparency and candour.
Implications for commissioners
The recommendations had significant implications for commissioners – their role in ensuring providers were delivering safe and quality care was considered paramount. The report recommended that they should be required to detect signs of failure in clinical safety and quality, and act upon them and use contracts and incentives to influence provider change.
The report recommended that commissioners should set safety and quality standards alongside the fundamental standards proposed (to be required and enforced by the Care Quality Commission). Furthermore, commissioners should develop long-term developmental goals for providers and play a stronger monitoring role.
Patient satisfaction and redress
Francis recommended that commissioners should monitor complaints and their outcomes on a real-time basis (as near as possible to) and should be able to intervene to manage individual complaints on behalf of patients if they believed that the complaint was being handled poorly.
Commissioners should develop contingency plans with regard to protecting patients from harm where it was found they were at risk from substandard or unsafe services.
Multiple providers and choice
The Francis report recommended that commissioners should ensure they could identify and were able to procure services from a range of providers in order to reduce reliance on one provider and give commissioners levers to drive up quality and offer choice to patients.
Commissioners should decide what services their local communities needed and consult with clinicians to ensure their proposals and plans were viable and appropriate. Additionally, they should make information and data on provider progress available publicly to enable people to make informed choices about their care.
The report also stated that:
‘The development of commissioning from its origins in the purchaser–provider split of the 1990s was characterised by a theoretical emphasis on improving the quality of service without great attention being paid to the tools with which to deliver this. The emphasis in practice was on financial control, and in relation to quality the balance of bargaining power remained firmly in the hands of the provider organisations...
Throughout the period under review the purchaser/commissioning arm of the system was subjected to repeated reorganisation, usually taking place well before it had been possible to put fully into practice and embed the aspirations of the previous changes. The time and resources required to be devoted to reorganisation undoubtedly made it more difficult for PCTs to develop effective methods of imposing standard quality requirements and of monitoring their delivery.’