'The Mid Staffordshire NHS Foundation Trust Public Inquiry' final report

The public inquiry into Mid Staffordshire NHS Foundation Trust published its final report on 6 February 2013, with 290 recommendations on care standards, the need for openness, transparency and candour, public access to accurate information, stronger patient involvement and cultural change.

Background

In 2010 an independent inquiry chaired by Sir Robert Francis QC had laid bare failures in the care provided by Mid Staffordshire NHS Foundation Trust between 2005–09. Andy Burnham, Secretary of State for Health prior to the 2010 general election, accepted Sir Robert's recommendation to hold a second, wider-ranging inquiry into why the failings at the trust had not been identified earlier by the commissioning, supervisory and regulatory system. Shortly after the election, Andrew Lansley – Burnham's successor as Health Secretary – converted the second inquiry into a full public inquiry.

The Francis report

The Francis report described how various warning signs relating to deteriorating quality had not been picked up by the wider system and suggested that senior managers at the trust had prioritised financial considerations over quality of care, in its quest to become a foundation trust. Despite being scrutinised by the local strategic health authority, the Department of Health and Monitor, the trust was authorised as a foundation trust shortly before the Healthcare Commission launched a special investigation, sparked by unresolved concerns about mortality rate alerts for some conditions.

The inquiry report suggested that the responsibilities and accountabilities of external agencies between 2005–09 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.

Francis stated: '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.'

While the Care Quality Commission (CQC) had not been in existence during the time of the inquiry period, it came in for heavy criticism in the report. Francis suggested that there had been evidence of a 'defensive, institutional instinct to attack those who criticise it.'

Related reviews

On 10 July 2013, following the publication of the Francis inquiry, Camilla Cavendish published her review into the training and regulation of healthcare assistants (HCAs) and social care support workers. The review proposed that all HCAs and social care support workers should undergo a certain level of basic training and should obtain a standard 'certificate of fundamental care' before being able to care for people without supervision.

Government response

Initial response

The government published its initial response to the Mid Staffordshire NHS Foundation Trust public inquiry on 28 March 2013.

The government suggested that the report represented a watershed moment for the NHS and that, while the case at Mid Staffordshire was unique in its severity, pockets of poor care were prevalent in other settings. While the focus of the government's response was on hospital care, there were implications for all sectors, including adult social care.

The government announced that the Care Quality Commission would appoint a chief inspector of social care, who would be responsible for developing a ratings system for social care providers.

The response also proposed that from April 2013, NHS Choices would include new information on care and support and would host an online facility for the public to post comments on their experiences. The intention was that this would enable the public and service users to compare different providers and make more informed choices, while allowing providers to act on feedback.

Full response

In November 2013, the government published Hard truths, outlining its full response to the Report of the Mid Staffordshire NHS Foundation Trust public inquiry. The response stated: 'Patients and the public are entitled to expect that when problems occur in the NHS, they are detected and dealt with promptly. That is why the government, working with the Care Quality Commission, is putting in place an effective and powerful system of hospital inspection, headed by the new chief inspector of hospitals.'

Actions

The government further outlined the actions that had been undertaken since its interim response in March 2013, namely:

• the appointment of three chief inspectors
• the commencement of the first wave of a new, tougher inspection regime
• a review by the NHS medical director into the trusts with the highest mortality rates, which resulted in 11 trusts being placed into special measures
• the consultation by the Care Quality Commission (CQC) on a new set of fundamental standards and a new system of ratings
• the introduction of a new failure regime, which was better able to deal with failures of both quality and finance
• the introduction of legislation to make the CQC more independent of government
• the publication of clinical outcomes by consultants for 10 medical specialities and the publication of data on the friends and family test.

The government committed to further action in the following areas:

• further clarity on the process for raising concerns or making complaints, and the quarterly publication of complaints data at a trust level
• providers would be under a statutory duty of candour and profession guidance, and codes would be amended to reflect a professional duty of candour on individuals
• the government would legislate to hold people accountable for the worst failures of care
• the government would introduce a new fit and proper person test to act as a barring scheme
• a new 'care certificate', which would ensure that Health Care Assistants and support workers had received proper training before giving personal care to patients and service users
• the government would legislate to introduce a new criminal offence, applicable to care providers who supply or publish false or misleading information. The government set out proposals from a consultation on this on 27 February 2014
• ensuring that the CQC would involve patients, service users and the public in inspections to inform ratings
• social care inspections following pilots in the spring of 2014, with providers having been rated by March 2016.

Commissioning

The Francis report had concluded that commissioners could have been more effective in securing better quality services. The government response reiterated the need for commissioners to drive quality improvement through better contract management, involve the public and patients in commissioning decisions, and take a stronger role in identifying the delivery of poor services and imposing sanctions on providers.

The government explained that the NHS standard contract, NHS England's assurance of clinical commissioning groups (CCGs) and the development of commissioning support services would provide a structure which would enable commissioners to effectively scrutinise providers' services. While the government accepted many of the recommendations relating to commissioners, there was not full acceptance of recommendations relating to the role of commissioners in handling complaints and the role of commissioners in intervention.

Regarding complaints handling, the government felt that allowing commissioning bodies to intervene in the management of an individual complaint would undermine the fundamental principles of the NHS complaints system, where providers have the opportunity to resolve complaints prior to an ombudsman stage for any that remain unresolved.

The government also rejected a recommendation that commissioners should have powers of intervention, similar to the system regulators. It suggested that the role of commissioners was to arrange the provision of high quality services and to take direct action when contract terms were being broken. In contrast, the role of the regulators was to ensure that providers met specific standards.

Commissioners made little, if any difference, to the care of patients in Mid Staffordshire NHS Foundation Trust. Commissioning failed as a means of defence against poor care, and as a promoter of high quality care. The picture in the wider NHS and in social care has been more mixed. Over the past 20 years, commissioning has helped to deliver a range of improvements in quality, access to care, productivity and efficiency; but it has often failed to have the transformational impact on the quality of care that had been hoped for.

Dissolution of Mid Staffordshire 

On 26 February 2014, following recommendations from the trust special administrator, the Secretary of State Jeremy Hunt announced that Mid Staffordshire NHS Foundation Trust would be dissolved and that Stafford and Cannock Chase Hospitals should be operated by other local providers. Some local services would be moved away from Stafford Hospital and there was a broader question as to the ongoing sustainability of consultant-led obstetric services in the area.