Robert Francis has produced a disappointing report which could yet go on to have a profound impact on health services in this country. It is disappointing because its weaknesses should have been easy to avoid. It is embarrassingly verbose, the executive summary alone runs to 125 pages and has 290 recommendations − at least 130 of which could easily have been dispensed with. 

‘Francis is right that any effective regulatory system must reflect the reality of the NHS by considering quality and finance side by side’

At nearly three years, the inquiry took much too long and its recommendations are based on an analysis of a system which has gone through significant change. The report’s length and delay serve to confuse and undermine its often powerful messages. Any health secretary should think long and hard about commissioning a similar exercise − the inquiry model may well have outlived its usefulness. 

Mr Francis must now use his planned speaking engagements to cut through the murk. This is feasible because the report contains much good sense. In particular, three very significant themes emerge which could change the NHS for the better.

The first is accountability and transparency. The proposed statutory “duty of openness and transparency” requiring board members to “be truthful in any information given to a healthcare regulator or commissioner” would help ensure that care quality is central to any leadership discussion, especially when combined with the need for board directors to sign off “consistent” and “accurate” quality accounts.

The statutory “duty of candour” − which would make it an offence to obstruct the passing of information about “death or serious injury” to patients or regulators − supplies the belt and braces. The use of criminal law to give these measures teeth is unwelcome but may be necessary.

Undermining proposals

Mr Francis is also right that any effective regulatory system must reflect the reality of the NHS by considering quality and financial issues side by side. The Care Quality Commission is resisting the proposed transfer of powers from Monitor, insisting closer working can deliver what the inquiry chair demands. The two regulators should be given a year to prove their case.

The third important message is the need to properly recognise and support the key role played by healthcare assistants and to strengthen nursing quality through measures such as revalidation. The government will likely claim poverty in the face of some of his recommendations in this area. If so, the onus is on it to demonstrate how it will achieve the desired change by other methods.

‘Given the mixed nature of the inquiry’s findings, much depends on next month’s government response’

Unfortunately, in two areas he proposes changes which are likely to undermine the culture of openness, risk-based inspection and service improvement he wishes to encourage. The inquiry chair suggests regulators should adopt “a low threshold of suspicion” and proposes an “arm’s length independent investigation” of a bewilderingly wide range of complaints, including any which “involves issues about the nature and extent of the services commissioned”. 

He suggests local authority scrutiny committees should have investigatory powers and that every “serious incident of avoidable harm” should trigger a CQC inspection. Sometimes it is very easy to tell that Mr Francis is a lawyer.

However, the most worrying proposal in the Francis report is the suggestion that any death or serious harm resulting from a breach of broadly drawn “fundamental standards” would be a criminal offence. Leaving aside the question of whether the NHS needs another set of “standards” to deliver higher quality care, the threat of criminal penalties will undermine the development of a no-blame culture and encourage the growth of “defensive medicine”. 

Given the mixed nature of the inquiry’s findings, much depends on next month’s government response. The answer to whether the Francis report has been worth the long, long wait is that, sadly, only time will tell.