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The Francis report's 18 recommendations

The conclusions of the inquiry into Mid Staffordshire Foundation Trust.

Recommendation 1:

The trust must make its visible first priority the delivery of a high class standard of care to all its patients by putting their needs first. It should not provide a service in areas where it cannot achieve such a standard.

Recommendation 2: The secretary of state for health should consider whether he ought to request that Monitor - under the provisions of the Health Act 2009 - exercise its power of de-authorisation over Mid Staffordshire Foundation Trust. In the event of his deciding that continuation of foundation trust status is appropriate, the secretary of state should keep that decision under review.

Recommendation 3: The trust, together with the primary care trust, should promote the development of links with other NHS trusts and foundation trusts to enhance its ability to deliver up-to-date and high class standards of service provision and professional leadership.

Recommendation 4: The trust, in conjunction with the royal colleges, the deanery and the nursing school at Staffordshire University, should review its training programmes for all staff to ensure that high quality professional training and development is provided at all levels to and that high quality service is recognised and valued.

Recommendation 5: The board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The board should review audit processes and outcomes on a regular basis.

Recommendation 6: The board should review the trust’s arrangements for the management of complaints and incident reporting in the light of the findings of this report and ensure that it:

  • provides responses and resolutions to complaints which satisfy complainants;
  • ensures that staff are engaged in the process from the investigation of a complaint or an incident to the implementation of any lessons to be learned all part of the recommendation
  • minimises the risk of deficiencies exposed by the problems recurring; and
  • makes available full information on the matters reported, and the action to resolve deficiencies, to the board, the governors and the public.

Recommendation 7: Trust policies, procedures and practice regarding professional oversight and discipline should be reviewed in the light of the principles described in this report.

Recommendation 8: The board should give priority to ensuring that any member of staff who raises an honestly held concern about the standard or safety of the provision of services to patients is supported and protected from any adverse consequences, and should foster a culture of openness and insight.

Recommendation 9: In the light of the findings of this report, the secretary of state and Monitor should review the arrangements for the training, appointment, support and accountability of executive and non-executive directors of NHS trusts and NHS foundation trusts, with a view to creating and enforcing uniform professional standards for such posts by means of standards formulated and overseen by an independent body given powers of disciplinary sanction.

Recommendation 10: The board should review the management and leadership of the nursing staff to ensure that the principles described are complied with.

Recommendation 11: The board should review the management structure to ensure that clinical staff and their views are fully represented at all levels of the trust and that they are aware of concerns raised by clinicians on matters relating to the standard and safety of the service provided to patients.

Recommendation 12: The trust should review its record-keeping procedures in consultation with the clinical and nursing staff and regularly audit the standards of performance.

Recommendation 13: All wards admitting elderly, acutely ill patients in significant numbers should have multidisciplinary meetings, with consultant medical input, on a weekly basis. The level of specialist elderly care medical input should also be reviewed, and all nursing staff (including healthcare assistants) should have training in the diagnosis and management of acute confusion.

Recommendation 14: The trust should ensure that its nurses work to a published set of principles, focusing on safe patient care.

Recommendation 15: In view of the uncertainties surrounding the use of comparative mortality statistics in assessing hospital performance and the understanding of the term ‘excess’ deaths, an independent working group should be set up by the Department of Health to examine and report on the methodologies in use. It should make recommendations as to how such mortality statistics should be collected, analysed and published, both to promote public confidence and understanding of the process, and to assist hospitals in using such statistics as a prompt to examine particular areas of patient care.

Recommendation 16: The Department of Health should consider instigating an independent examination of the operation of commissioning, supervisory and regulatory bodies in relation to their monitoring role at Stafford hospital with the objective of learning lessons about how failing hospitals are identified.

Recommendation 17: The trust and the primary care trust should consider steps to enhance the rebuilding of public confidence in the trust.

Recommendation 18: All NHS trusts and foundation trusts responsible for the provision of hospital services should review their standards, governance and performance in the light of this report.

Source: Francis report

Readers' comments (13)

  • What a completely biased outcome. Where are the rest of the recommendations for the SHA, the DH, the Ministers, and the regulators to all do a better job. How culpable were they in all this?

    This country needs and wants a public inquiry.


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  • The regulators failed to prevent this tragedy, Anna Walker the former Chief Executive of the Healthcare Commission is now Chairman of the Office of the Rail Regulator the body responsible for railway safety.

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  • Paul Tovey

    Yeah - the sentiments above are so spot on ...

    Anon 1. Has it for me espcially - the financial hothousing of Staffs FT was driven by Gov't pressure - it happened at other Trusts too...

    The public are shut out too from accountability - hived off in quarantined "nice" little groups - of finally over-polite people that have more in common with the over-conformed set-up torturers like Stanley Milgram's experiments ably showed ...

    It not that people are inherently bad - they just overconform to "authority" which creates abuses and slip and slide on the vision of others pains


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  • The regulators certainly have some explaining to do. However every member of staff at Mid Staffs who knew of the shortcomings and the effect on the safety of patients is culpable. There needs to be a lot of soul searching regarding how staff could have participated in the deaths of so many patients.

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  • If regulators use data, then problems are bound to take some time to be identified. One death, however regrettable, is not a pattern and only over time can a problem be seen in any statistical analysis. Even then there are difficulties, as the report notes, and further work is needed on the methods of estimating patient deaths in hospital. Inspection is clearly able to spot problems on the day, especially if unannounced, but to inspect every part of the NHS would take a lot of resources. The Healthcare Commission was not, in my view, as an insider for three years, an effective manager of its own resources, and so current and future regulators might be able to do more even with a limited budget. But the professional and ancillary staff of a hospital are there every day and have the means to raise issues internally and externally. For me, the prime questions are around how bad things were on the ward and A&E and, if as bad as has been painted, why were staff not taking action to have the difficulties addressed? If they were stifled by the board, they still had recourse to other means of drawing attention to their concerns. Were they used? When I worked for a private sector company, it introduced a quality control system to manage our very diverse consulting project work. One partner said to me that, in the end, he thought it was a paperchase. "What drives quality in this company", he said, "is the pride in their work that should be taken by every member of staff." Surely we have to rely on the staff who are in a hospital 24/7 to maintain standards rather than inspectors who can only call in, even with much bigger teams than current regulators have at their disposal.

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  • If the Trust board have been told that under all circumstances they must meet 100% of Clinical targets, and 100% of finnacial targets and all Trust in England must become an FT by 2009 and if not you will be sacked then they will prioritise the tick box culture that the SHA wanted.

    If they are asked to provide safe and effective care and if you have finnacial problems manage in partnership across a region then that is something else but that was not the message from Ministers or DH or SHA, who should all hang their head in shame.

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  • It seems incredible that a Trust found to be delivering such a poor standard of care could retain its Foundation status. The fact that it was not immediately stripped of this, speaks volumes.

    Up and down the country Boards are obsessed with targets and balancing their books rather than the quality of care they deliver to patients. This is of what they are judged on by SHA's,DOH and ultimately their political masters. The values are set at the very top, and they are profoundly corrupt...and corrupting.
    Yet even more worrying in a way, is that clinical staff seem to regard the poor care THEY deliver as acceptable. They are not acting as Professionals. If they were, there would be a torrent of letters and reports to Royal Colleges, Trust Boards, Regulators and the media, not the occasional 'whistleblower'. Mid Staffs for example probably employs several thousand doctors, nurses, physios etc.
    'What did you do during the war daddy?'

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  • Star Geezer

    FTs across the country are faced with a serious dilema, they have struggled over the past couple of years with tightening financial contraints whilst at the same time trying to mainintain high clinical standards and morale. Many have done very well.

    This next wave of proposed cuts are not without serious risk of compromising care.
    Staff are caught between a rock and a hard place, the corporate teams need to acknowledge that and build in support to staff,safety nets for services who are clearly exposed and could repeat the mistakes of Mid Staffs.

    The external agenciea Monitor/CQC also need to factor in the risks involved in the next couple of years and start factoring in the period of austerity by simplyfying its expections to a more condensed set of standards, otherwise we are all set up to fail.
    At some point someone should be honest with the Public about the cuts, hospital closures and consequences. I guess that can wait till post election 2010.

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  • It is difficult to accept that nursing and medical staff ...and other clinicians all of whom have codes of conduct, can do other than hang their heads in shame if the situation was as bad as reported .As with Maidstone and Tunbridge Wells Trust ,the Board must be ultimately accountable and go ,but even if they were deaf to the trust staff there are many alternative mechanisms to get the point across and this is essential if any hospital is to maintain decent standards.It would be interesting to know if any of the senior clinicians took any actions to draw attention to the poor practices of their clinical colleagues.The Francis report seems helpful in setting out what in the most part should already in place, but none of the recommendations will be worth a jot if front line staff don't accept responsibility for maintaing and improving care standards day in day out.

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  • What about the accountability of the (so-called) NHS Chief Executive?

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  • So where was Monitor's failsafe regulatory oversight? Where was the compliance team? Where was the board's 'famed' tough intervention regime? Answers: Nowhere to be seen; failed to spot the problems; clearly not brought to bear.

    Is this the beginning of the end for the local autonomy of FTs? SHA oversight is arguably better understood and better in terms of application nad efficacy.

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  • I hope that Human Resource Departments procedures will also come under vigorous scrutiny. Managers from my experience appear to rely on "advice" from HR or are frightened to challenge them, on taking disciplinary action. A lack of perspective and common sense leads to unnecessary waste of time and resources that should be directed to issues that really matter.
    The harsh Blame Culture that is now so prominent means that clinical staff are under pressure to not highlight things that go wrong so they can be dealt with. If this is not dealt with these recommendations will be toothless.

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  • To all of the above, you are reading 18 of the 290 recommendations from the Francis report. Read the report not what some person thinks is the most important 18!!!!! Peter West and Star geezer are the only two people who actually understand what has gone on. Which is a failing in the system, When the government puts pressure on trusts to meet business targets and to run as a business, priorities change, cuts get done and you try to manage with limited resources, this is not something that should be done in the NHS! Even after the Francis report the government still wants all NHS trusts to make 4% savings/cuts on their budgets. The Francis report highlights that Staffordshire prioritised this over patients, and yet it is still expected to happen regardless

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