This decade has been one of the most politically charged in NHS history. We’ve seen the largest upheaval of the health service since its foundation, the first ever all-out strike of junior doctors, and a big 70th birthday present in the form of a funding settlement. But when it comes to the values at the heart of the NHS – compassion, high-quality care and protecting the vulnerable – nothing prompted more soul-searching this decade than the Francis Inquiry into the failings at Mid Staffordshire Foundation NHS Trust.
The Inquiry had far-reaching consequences for healthcare policy, delivery and regulation as leaders set out to make sure the unacceptable standards that were allowed to proliferate at the Trust would never be tolerated again.
Yet, five years on, 2018 has already been rocked by the details of another patient scandal where hundreds of lives were shortened at Gosport War Memorial Hospital between 1988 and 2000. With recent polling from the British Medical Association finding that 78 per cent of doctors think underfunding has significantly affected quality and safety in the NHS, leading experts fear we are increasingly at risk of another scandal taking place.
As the present-day NHS faces a similar perfect storm of financial pressures, staff shortages and rising demand, the question remains: has government and the NHS done enough to ensure history doesn’t repeat itself?
In order to answer this question, we must first look at the factors that contributed to the failings in the first place and the reforms that followed.
The shocking events that took place at Stafford Hospital between 2005 and 2009 have been described as a story of “appalling and unnecessary suffering of hundreds of people” where “the most basic standards of care were not observed, and fundamental rights to dignity were not respected.”
After several reports and investigations into poor care at the hospital and a long-fought campaign by relatives and victims to bring the scandal to national attention, Andrew Lansley announced a full public inquiry into the failings at Mid Staffordshire Foundation NHS Trust in 2010.
Following consideration of one million pages of evidence and over 250 witnesses, Robert Francis QC published his Inquiry Report in February 2013. His scathing report diagnosed the failings as the consequences of a negative culture where victims were “failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.” An unwavering focus on meeting quantitative targets, balancing the books and seeking foundation trust status, were all cited as contributory factors. This was a system failure that required a systemic response.
Francis made 290 recommendations in total including a legal ‘duty of candour’ to oblige staff to be honest and open in all their dealings with patients; consistent training for healthcare support workers; and the introduction of a ‘fit and proper person test’ for NHS Directors.
The Report presented the Coalition Government with a dilemma. Jeremy Hunt, then still a green Health Secretary, needed to show political leadership through a robust response that quickly re-built the trust of the general public. But equally, the government had to address complex internal NHS cultural issues, for which there was no easy or quick fix. Furthermore, they had to do this without any wholesale re-organisation of the NHS (the health service was still reeling from the Health and Social Care Act) or the kind of burdensome targets which are widely believed to have created the negative culture in the first place.
The Government set about accepting all but a handful of Francis’ recommendations.
One of their first actions was to create the new post of Chief Inspector of Hospitals to take personal responsibility for a tougher Ofsted-style healthcare inspection regime. The new team at CQC had already started reforming its inspection regime but David Cameron and Jeremy Hunt took the opportunity to re-invigorate and re-focus the process and compel the CQC to start the inspection regime the same year.
The approach was largely endorsed by stakeholders in its first phase. Research from the Kings Fund and Manchester Business School in 2014 found that it was regarded as “much more credible, authoritative, rigorous and in-depth and much less likely to miss any issues of significant concern.” It will need more time before any thorough assessment of the impact these ratings have had on quality improvement.
Nursing shortages were also brought into sharp focus by the Inquiry. There was much debate at the time around the introduction of a minimum safe staffing level, leaving Hunt to set out on a nursing recruitment drive instead. Politically, this was relatively well-received and while he was Health Secretary, Hunt was quick to wheel out the figures showing that the number of doctors and nurses working for the NHS have increased in their thousands since 2012. However, while numbers have risen (by a debatable amount, depending on what month you look at the figures!) so has demand. Moreover, the drive to recruit staff was not met with similar levels of capacity to supply staff, resulting in a reliance on agency staff that many believe contributed to the service’s financial woes.
While evidence shows that many Trusts invested in medical and nursing staff following the Report, this has waned to some extent both due to financial pressures and shortages in the supply of staff. Five years later, the NHS still suffers from significant workforce pressures which are only likely to be exacerbated by Brexit.
It’s at a Trust level where the Report has had the biggest impact. Evidence shows many trusts revised their policies on whistleblowing, complaints handling, staff engagement and incident reporting in the years following the report. There are also many heartening examples across the NHS of a commitment to improving patient safety, for example staff challenging each other about care standards. Research from Alliance Manchester Business School, the Nuffield Trust and Birmingham University, also reveals that Trusts have not only complied with the duty of candour but have “embraced” it.
No-one can deny that the Francis Inquiry was a driver for positive change, particularly amongst NHS leadership. It re-focused attention on patient safety and, along with a host of interrelated reports throughout the decade, ensured it stayed on the agenda. But increasing demand and financial pressures, coupled with workforce woes and conflicting policies, are threatening improvements.
74 per cent of doctors still think financial targets are being put above patient care. While the birthday injection of cash is welcome, it won’t be seen until next April and is unlikely to bring an end to a focus on productivity, efficiency and financial targets. Until we find long-term solutions for these problems, trusts will always be walking the fine line between reconciling patient safety with the need to balance the books.
When it comes to changing an organisation’s culture of safety, there are also no easy answers. During his time as Health Secretary, Hunt admitted many staff still feel “terrified” to speak up when things go wrong. He would have been hoping his controversial Draft Health Service Safety Investigations Bill puts paid to that. But with 95 per cent of doctors still afraid of making an error and a new Health Secretary in post there is still some way to go.
It is said that Jeremy Hunt met with many of the families in private in the wake of Francis and this clearly had an impact on his approach. Perhaps his biggest legacy will be that he learned the most important lesson of all from Francis: being open and honest about the problems in front of you is the only way forward.
Emily Cameron, Senior Account Director