Live comment, analysis and reaction to the Francis inquiry into systemic failure to safeguard patients at Mid Staffordshire Foundation Trust.

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Following the publication of the Francis report:

  • Jeremy Hunt says Monitor will survive as an economic regulator.
  • The CQC doesn’t want to merge with them anyway.
  • NHS medical director Sir Bruce Keogh will investigate five trusts with high death rates. Full coverage of the Keogh review
  • The government will respond in full to the 290 Francis recommendations next month.
  • Trust boards could be suspended for quality failures as well as losing control of the money, PM says.
  • Don Berwick, who led president Barack Obama’s healthcare reforms in the US − to “make zero harm a reality in our NHS”.
  • Government to ask the CQC to create the post of chief inspector of hospitals. A new inspection regime will begin in the autumn.
  • Ministers will take advice on how NHS hospitals should handle patient complaints.

The main news lines from the Francis report are:

  • Francis calls for CQC to take on Monitor duties
  • Report stops short of regulation for managers
  • Directors of NHS providers should be subject to a new fit and proper person test
  • Healthcare assistants should be regulated by NMC
  • New laws recommended requiring all NHS staff and directors to be open and honest when mistakes happen
  • NICE should draw up standards for clinical skill mix and minimum staffing levels
  • Little direct criticism of specific NHS leaders, including Sir David Nicholson
  • RCN should consider splitting trade union and professional body roles
  • 290 recommendations in total

7.14pm And - we’re done for today. It’s been a momentous day for health policy. We’ll leave you with one final thought from patient representative body National Voices. They tweet: “Is the Francis report big enough to see from space?” Goodnight!

7.11pm A final story from our reporter Shaun Lintern. “Robert Francis has backed the slowing down of the foundation trust pipeline process in order to ‘make sure’ trusts completing the process are safe.

“In an in-depth interview with HSJ today Mr Francis said he was not calling for the full abolition of the foundation trust regulator Monitor. He said foundation trust applications needed to be assessed by one organisation - the Care Quality Commission.” Click here to read the whole interview.

7.07pm We’re just beginning to think about maybe slowing down our coverage for the evening.

But before we do, here are some highlights from the national press today.

Here’s a profile of Robert Francis from the Independent.

Here’s the Telegraph’s summary of the Francis recommendations.

And, here’s the Guardian’s.

Judith Smith, policy director of the Nuffield Trust, writes on the Guardian’s Healthcare Leaders Network that Francis shows the NHS is not the national treasure we thought it was.

Meanwhile, “the Francis report exposes how the NHS has been infected by the worst trade union and corporate attitudes”, Christina Odone blogs for the Telegraph.

“Staff will only work certain hours and will mutiny the minute there’s talk of a wage freeze. But it’s not just the bloshie attitude of a labour unionist that the NHS has picked up. It also has the worst of the greedy corporate mind set: Francis reveals how the clipboard apparatchiks were ready to compromise standards in chasing profits, and talked casually of restructuring as if a hospital were a widgets manufacturer.

“There is no room, on the factory floor or in the corporate corridors, for old-fashioned values like care, nurturing, dignity, decency. Yet this is what we expect of a good health service. The NHS must show us it can be that, again.”

6.53pm The interactive infographic explaining how the Francis report will affect the key players in the NHS has been updated. Click here to explore.

6.50pm One more story that slipped through the net earlier today: Minimum safe staffing levels should be drawn up by the National Institute for Clinical Excellence and policed by the Care Quality Commission, according to the Francis report.

6.37pm The NHS Leadership Academy has issued a statement. You can view the whole thing here.

Managing director Jan Sobieraj says: “[Francis] specifically says that ‘a leadership college should be created to provide common professional training in management and leadership’ and that it ‘should be a physical presence that will serve the role of reinforcing the required culture through shared experience and will provide a common induction into the expectations of the NHS of those who lead and work in the system.’

“The NHS Leadership Academy is, I believe, the organisation Robert Francis envisions for the NHS.”

6.27pm A couple more responses to the Francis report. Jon Restell, chief executive of the NHS managers’ union Managers in Partnership said: “We welcome this strong, comprehensive report that will resonate with MiP members in management throughout the NHS. The thrust of it reinforces the values of public service, compassion and care that lead people to work for the NHS. These values were betrayed by the avoidable suffering of the patients at Stafford hospital. The legacy of their suffering must be permanent cultural change at all levels of the NHS. We must make the Francis report the last of its kind in the NHS.

“There will of course be questions about the detail and how recommendations may work or be resourced, but we welcome the focus on culture, and not structures.

“For us there are two critical safeguards for care standards: first, strongly motivated and committed staff (both managerial and clinical); and second, listening to patients and carers and acting on their concerns. Better, rather than more, regulation should focus on these two factors.

“We will study the recommendations and the government’s initial response. As a union of managers, we welcome this opportunity to change the culture of the NHS. Members are already asking how they can get involved in our work on the Francis agenda.”

6.17pm More Nicholson news. The NHS Commissioning Board has just uploaded this six minute Youtube video. In it, Sir David says: “it’s important that we in the NHS reflect soberly and sensitively on what happened [at Mid Staffordshire], and what needs to happen, what actions we need to take to make sure such things never happen again.”

6.11pm So - after a robust performance on Radio 4 and little in the way of direct criticism from Robert Francis, can we assume Sir David Nicholson is safe in his position as chief executive of the NHS?

Not just yet, no. The Daily Mail’s homepage was briefly dominated by a story with the following headline: “1,200 deaths, a damning report on ‘failings at every level’ and 290 recommendations for reform. Now families of the Stafford Hospital victims and union chiefs call for the head of the NHS to resign”.

The story is still live, but has been replaced on the homepage by a story about a cute toddler catching a train.

The point is this: The Daily Mail has the most popular English language news site on the planet, and its influence on UK politics is enormous. If they decide to pursue Sir David, his stituation could still become very uncomfortable.

5.55pm Sir David Nicholson told Eddie Mair, as he told HSJ some weeks ago - that he considered resigning when he read the first Francis report from 2010, which only focused on the failures of care at the hospital, rather than the entire systemic failure.

Mr Mair tried to pin Sir David down on the weak patient voice represented by Healthwatch, which another guest had described as useless (see 5.34pm, below). Sir David talked about the wider checks and balances in the system, including patient representation on CCGs, and health overview and scrutiny committees.

Sir David said that he was “shocked but unsurprised” at the findings of today’s report. But, he said, refocusing NHS management away from targets and onto the needs of patients was one of the main things he wanted to accomplish when he applied for his current job.

5.44pm Sir David Nicholson has been on Radio 4’s PM current affairs programme. Key lines to follow.

5.36pm Another Francis reaction blog. Dean Royles, director of NHS Employers, has written an article for on what he thinks the Francis report means for the NHS workforce.

He says: “The report contains some recommendations that will certainly impact on the way we work, manage and lead our organisations. Away from the headlines about the role of regulators and national organisations, what we are left with is recommendations at the heart of our people management practices.”

5.34pm Local Healthwatch is the “weakest and most useless” patient representative body since 2003, Malcolm Alexander, chair of Action Against Medical Accidents tells Radio 4.

5.32pm Nicholson appears to be doing the rounds. He’s just been on ITV news ahead of his grilling on Radio 4.

5.30pm Ahead of Sir David Nicholson’s appearance on the PM programme Jeremy Hunt has been interviewed by Eddie Mair.

Key lines, courtesy of Ben Clover’s Twitter stream:

“If they need more money to do this (the CQC) they shall have it”

“EM: Do you trust Nicholson? JH: He is one of the best managers in the country”

“JH: Not my job to say someone is innocent or guilty but it is my job to make sure the system works properly. There were bad apples”

“Eddie Mair suggests DN not held to same standards of accountability as nurses “

5.21pm NHS Commissioning Board Sir David Nicholson is going to appear on BBC Radio 4’s PM programme some time after 5.30pm. Stand by for updates.

5.15pm HSJ chief reporter Dave West has interviewed health secretary Jeremy Hunt. Monitor will survive and is likely to take regulation and enforcement action, while the Care Quality Commission focuses on inspection, he said.

Monitor would continue as an economic regulator, and would probably run the “single failure regime” for providers announced by the prime minister in Parliament today.

Read the whole thing here.

5.12pm A rare statement from Department of Health permanent secretary Una O’Brien. It’s heavy on the apology, light on specific action for the time being.

She said: “On behalf of the Department of Health, I would like to apologise wholeheartedly for the part the department played in the failings at Mid Staffs and the terrible impact it had on patients, their families and the standards of care.

“We will take action on the recommendations from Robert Francis QC.  We are committed to a renewed focus on putting patients at the centre of everything we do.

“In response to the Francis report, we will be considering more profoundly our own behaviours as the steward of the health and care system and how we can do more to listen to patients and truly understand their experience of illness, care and recovery.

“I know all our staff are reflecting deeply on the report today, and we will be making plans over the coming days and weeks for the actions we all need to take.”

“The Department will be considering in full the recommendations made in the report, and will be responding in further detail next month.”

5.08pm More analysis of the Francis report. Francis recommends criminalising failures in duty of candour, reports Ben Clover. Robert Francis QC has recommended it be made a crime to obstruct the duty of candour or make an “untruthful statement to a commissioner or regulator”.

The proposal would have “wide ranging” consequences, for instance in corporate manslaughter cases and inquests, one lawyer said.

5.04pm We’re aware it’s gone 5, but don’t tune out yet - we’re not going anywhere and there’s still loads more on Francis for you to read. James Illman reports: Obama adviser to make ‘zero harm in the NHS a reality’.

“Don Berwick, the man who advised President Obama on his health reforms, has been appointed to spearhead a “zero harm” agenda in the NHS, David Cameron has revealed.

“The eye-catching appointment is potentially a substantial coup for the prime minister, who announced the move to the House of Commons this afternoon.

“Mr Berwick previously advised President Clinton and is regarded as one of the world’s leading health advisers.”

5.01pm Crispin Dowler has been looking at the Francis report’s conclusions around the systemic failure of the NHS as a whole. “A “plethora” of agencies, commissioners, regulators and professional bodies failed for years to act on warning signs which should have alerted the NHS system to serious failings at Mid Staffordshire Foundation Trust,” the report says.

4.54pm An HSJ exclusive story - CQC chair David Prior has just told reporter Sarah Calkin that the regulator wants to avoid merging with Monitor if at all possible.

Robert Francis QC recommended the CQC takes on Monitor’s functions for “corporate governance” and “financial competence”.

However, Sarah reports, “CQC chair David Prior told HSJ his initial response was that it would not be good for the CQC to go through any formal merger with Monitor. He also said the objectives of Mr Francis’ recommendation could be achieved through closer working.”

Mr Prior said: “We can probably achieve what Robert Francis wants us to achieve without a formal merger with Monitor… The history of the CQC is of three mergers that happened six years ago and the ramifications are still being felt.”

4.51pm HSJ editor Alastair McLellan has been musing on what the Francis report means for the HSJ 100 power list.

The top five in November last year were: 1) Sir David Nicholson of the NHS Commissioning Board 2) Robert Francis 3) David Bennet of Monitor 4) Health Secretary Jeremy Hunt 5) David Behan of the CQC.

Alastair tweets: “After #Francis report I’d say the order runs 1) Nicholson 2) Behan 3) Hunt 4) Francis 5) Bennett.”

4.45pm More HSJ news: The chief nurse role should be ‘kept under review’, the Francis report has recommended.

Contributing editor Steve Ford writes: “The government’s splitting of the chief nursing officer role in England into two positions should be ‘kept under review’, according to the Mid Staffordshire Foundation Trust public inquiry report.

“As part of the government’s reforms, the post of the CNO for England was restructured, with a CNO being appointed to the new NHS Commissioning Board and a director of nursing appointed at the Department of Health.

“The CNO is currently Jane Cummings and the DH director of nursing is Viv Bennett. They replaced Dame Christine Beasley.

“Concerns were raised last year that the splitting of the role might dilute the nursing voice at senior NHS level, though others argued that the opposite was true and having two senior voices was better than one.” Read the full story here.

4.42pm Paul Waugh, the editor of the Politics Home website has been in a press briefing with Number 10 this afternoon.

He tweets: “No.10, asked if PM has ‘full confidence’ in David Nicholson: ‘Yes. Both the PM and Secretary of State think Sir David is doing a good job’”

“No.10 spksman re Cam on #MidStaffs: ‘He was noting the fact that Sir David has previously kind of apologised.’”

4.39pm Health secretary Jeremy Hunt tweets: “Moving words by PM on Mid-Staffs tragedy - my challenge is 2 be able 2 look Stafford families in eye & say I’ve turned words into action.” Possibly his first public words since the publication of the Francis report.

4.32pm Another story from the HSJ news team. Ben Clover has produced this piece on the Keogh investigation into mortality outliers.

He writes that four NHS trusts had a higher than expected mortality rate in each of the data sets published up to October 2012. The four are: Blackpool Teaching Hospitals Foundation Trust, George Eliot Hospital Trust, East and North Hertfordshire Trust and Tameside Hospital Trust.

Interestingly, only Blackpool and Tameside are part of the Keogh review - although he will be visiting another three trusts (see the liveblog entry for 4.07pm). We expect this is because the NHS Commissioning Board has access to a more recent data set than the ones Ben saw in October.

4.21pm A long and detailed response to the Francis report from the General Medical Council can be found here.

It includes this answer to the government, who asked the GMC what they had done about the doctors who failed patients at Mid Staffordshire.

Chief executive Niall Dickson said: “We have investigated 42 doctors from Mid-Staffs and have sought to keep the inquiry updated on the progress of these cases. Twenty-two of the doctors have received formal letters from us advising them about their future conduct, one has accepted restrictions on their practice, and a further eight are subject to ongoing active investigation; four of whom are due to appear shortly before a public hearing. If they are found guilty, there will be sanctions including the possible loss of their registration.”

4.10pm We’ve just published a blog by Centre for Mental Health chief executive Sean Duggan considering what Robert Francis’ recommendations could mean for mental health care:

“The Francis report demands a considered and timely response,” he writes. “That should include a full assessment of what any actions will entail for mental health services and their partners, inside and outside the NHS. How, for instance, can we ensure that the proposed new standards and the ‘duty of candor’ help to protect detained patients and those on community treatment orders?”

4.07pm The NHS Commissioning Board has named the five providers who will be investigated by NHS medical director Sir Bruce Keogh. They are:

Colchester Hospital University NHS Foundation Trust;

Tameside Hospital NHS Foundation Trust;

Blackpool Teaching Hospitals NHS Foundation Trust;

Basildon and Thurrock University Hospitals NHS Foundation Trust; and

East Lancashire Hospitals NHS Trust.

All have been outliers on summary hospital-level mortality indicator (SHMI) data for two successive years to 2012.

4.01pm We are. frankly, a little snowed under with responses to the Francis report at this stage in the afternoon. The one from the NHS Confederation is here, though.

3.59pm Nuffield Trust chief executive Jennifer Dixon’s response is the first we’ve seen from a major health policy commentator which is less than wholeheartedly supportive of the Francis recommendations.

She said that, while there is “much to commend in Robert Francis’ report and it is broadly in the right direction”. The inquiry’s conclusions and recommendations must be “considered in detail before we embark on ways to tackle the more systemic problems raised”.

Ms Dixon said: “In particular, I would question the wisdom of merging the CQC and Monitor as it would bring further organisational upheaval at a time of huge financial challenge. There are more pressing priorities and structural remedies often don’t deliver the solutions they set out to. The history of merging already large regulators is mixed at best and we should proceed cautiously.”

3.53pm Anna Dixon, director of policy at the King’s Fund welcomed the Francis report, but adds: “Even if all 290 recommendations were implemented now, the fundamental shift in culture can only be achieved if patient care is put top of the agenda for boards and is the first responsibility of professionals working in the NHS. That will take time and commitment over many years.”

3.42pm Monitor have released their statement on Francis. It doesn’t say much about the Francis recommendation to give some of their duties to the CQC - simply that structural changes are a matter for the government.

The regulator “profoundly and sincerely regrets the events that took place at Mid Staffordshire Foundation Trust during the period covered by the public inquiry”.

The statement continues: “We accept without hesitation our share of responsibility for failures in regulation during the period in question. We authorised a trust which in retrospect should not have been authorised and could have used our formal intervention powers sooner once problems had been uncovered.

“We have learnt from the mistakes we made and have already made significant changes to the way we work as a result of what happened at Mid Staffordshire.

“For example: We will not authorise an NHS Trust without the Care Quality Commission’s assurance that it has no major concerns about the quality of care; we incorporate an explicit assessment of a Board’s role in ensuring the quality of care into our regulatory judgement about whether a foundation trust, or a trust applying for foundation status, is well-run; we work very closely with the CQC, sharing information about concerns in foundation trusts and applicant trusts, and jointly commissioning further investigations where necessary; and we take action as soon as problems are identified in foundation trusts, using our statutory powers when that’s the best way to bring about change.

“In preparing for our expanded role as sector regulator we are continuing this strong emphasis on quality governance in foundation trusts and we continue to work closely with the Care Quality Commission.”

The statement goes on to welcome the Francis report and promises to study it carefully for new lessons. “Any further changes to the structure of regulation are necessarily a matter for government,” it concludes.

3.37pm CQC chief executive David Behan has responded to the Francis report. He’s considering going further than the Prime Minister’s recommendations to establish a chief inspector of hospitals, and setting up a chief inspector of social care, too.

He said: “Robert Francis’s report is defining for everyone involved in healthcare. People were badly let down by the NHS and those responsible for healthcare regulation and supervision. Our thoughts are with the families who have suffered. This kind of long term failure must not happen again.

“No system can guarantee that there will never be failings. Regulators and supervisory bodies must be much better at identifying and challenging poor care and in working together to improve people’s experiences of care. And boards, managers, care staff and commissioners must take responsibility. And we must all listen to patients.”

“Today’s statement by the prime minister sets clear objectives for CQC which strengthens our role as regulator. We will continue to operate as a single, unified regulator across health and social care.

“In his statement today the Prime Minister asked CQC to bring forward proposals to appoint a chief inspector of hospitals. The appointment of a chief Inspector of hospitals will enable us to put a sharper focus on hospital care – really getting to grips with what’s most important to patients and their families. As the Prime Minster said, this will help to ensure hospitals are clean, safe and caring.”

He said the Prime Minister’s statement reinforces changes already underway in the CQC.

These are to look more closely at how hospitals are run. Simply put, do the doctors  talk to the managers, do board members talk to patients, how well do hospitals learn from mistakes and complaints? We will use more clinical experts in our inspection teams - if it’s about nursing, we will take a nurse with us - and we will involve more members of the public with direct experience of hospital care - ‘experts by experience’ – in our inspections.

“We will look at how we can develop teams of specialist inspectors, who will work alongside clinical experts and people who use services.

“We will listen much harder to what people who use services tell us about the reality of the care they receive. And we will work more closely with others and use a wider range of information and evidence in our assessment of quality and performance.

“We are changing our board and the way it works.

“We believe that Robert Francis’s recommendations in relation to a positive patient culture apply across all health and social care and we also will consider appointing a chief inspector for social care.”

3.29pm HSJ’s Ben Clover tweets that Monitor chief executive and acting chair David Bennett and CQC chief executive David Behan have been “summoned in to see [DH permanent secretary] Una O Brien this afternoon.” Maybe Monitor’s statement will follow after that, he speculates.

3.24pm Some more on David Cameron’s speech. You can read his official response in full here. HSJ finance reporter Crispin Dowler tweets “am still not exactly sure what PM means by “failure regime” in this context”. His point is that under existing rules, Monitor (for foundation trusts) or the DH (for everyone else) already have the power to suspend boards for finance or governance failures.

The “failure regime”, as the term is normally understood, is effectively an insolvency mechanism which enables a broader set of actions, including sanctions on the board but also the breakup of a trust or the reorganisation of services to make the body sustainable.

3.10pm Here’s a round up of the key points from David Cameron’s speech:

  • The Prime Minister told Parliament that Robert Francis QC had identified “three fundamental problems with the culture of the NHS”. These were a “focus on finance and figures at the expense of patient care”, an attitude that “patient care was always someone else’s problem” and “defensiveness and complacency instead of facing up to data which should have implied a cause for concern”.
  • The government will respond in full to the 290 Francis recommendations next month.
  • Ministers will extend the failure regime for NHS trusts to include care quality failures. Trust boards will be able to be suspended for that as well losing control of the finances.
  • Don Berwick, who led president Barack Obama’s healthcare reforms in the US − to “make zero harm a reality in our NHS”.
  • As briefed to the Sun, Daily Mail and Telegraph, Mr Cameron said he would ask the CQC to create the post of chief inspector of hospitals, to take responsibility for a system of hospital inspections modelled on Ofsted’s inspections of schools. The new regime will begin in the autumn.
  • NHS medical director Sir Bruce Keogh will conduct “an immediate investigation into the care of hospitals with the highest mortality rates and to check that urgent remedial action is being taken”.
  • The Prime Minister has also asked South Tees Hospitals Foundation Trust chief executive Tricia Hart and Labour MP Ann Clwyd to advise on how NHS hospitals should handle patient complaints.

3.01pm There hasn’t been a statement from Monitor yet - that’s a little surprising, given that the Francis report has recommended taking lots of functions away from them and giving them to the CQC.

3pm Here’s HSJ’s story on Prime Minister David Cameron’s speech to Parliament this afternoon. The top line: that the government intends to extend the failure regime to enable the suspension of trust boards for care quality failure, not just financial failure.

2.47pm Have a look at this interactive infographic on how the Francis report affects key players in the NHS, including chief executive Sir David Nicholson, the Department of Health, secretary of state Jeremy Hunt, Monitor and the CQC.

2.45pm Prime Minister David Cameron sounded decidedly lukewarm on the subject of healthcare assistant regulation. Robert Francis recommended that HCAs be regulated by the Nursing and Midwifery Council. However, speaking in Parliament this afternoon, Mr Cameron said “proper training standards” was a good idea, but regulation was “more bureaucratic and complicated”. He didn’t sound keen, HSJ editor Alastair McLellan tweeted.

2.41pm Analysis of the Francis report and the government’s response to it is only just beginning this afternoon. Here is what we know so far:

  • Robert Francis’s exhaustive, three-volume report has recommended the Care Quality Commission take on Monitor’s responsibilities for overseeing the corporate governance and financial competence of foundation trusts. Exactly how that would work in practice is unclear, but it could leave Monitor as purely an economic regulator.
  • Directors of NHS provider organisations should be subject to a new “fit and proper person test”. However, the report stopped short of calling for statutory regulation of NHS managers.
  • There has been little direct criticism of individual NHS leaders, including chief executive Sir David Nicholson
  • Healthcare support workers should be regulated by the Nursing and Midwifery Council.
  • The National Institute for Health and Clinical Excellence should draw up guidelines for ward skill mix and minimum staffing levels.
  • The Francis report has recommended revalidation for nurses. The report calls for the Department of Health and the NMC to develop the idea of a Responsible Officer for Nursing, and for a system of annual revalidation similar to doctors to be created. Nurses would have to demonstrate key skills and knowledge and include feedback from patients.
  • The Francis report is damning about the Royal College of Nursing. Robert Francis has described the RCN as “ineffective” both as a professional organisation and as a trade union, and it should consider separating its two roles.
  • The report has been widely welcomed by almost everyone, even the Royal College of Nursing. The Unite union is still calling for Sir David Nicholson to resign.

1.50pm One more response, then we’ll do a recap of the key points so far today.

Here’s the British Medical Association’s reaction to the Francis report.

BMA chair of council, Dr Mark Porter, said: “It is not enough to say that lessons must be learnt. It is essential that we all - politicians, NHS organisations, doctors, managers, nurses, and patient groups - work together to develop a different kind of health service where the system will not tolerate poor quality of care.

“We must urgently develop a new culture - everyone working in the health service must play their part, and be allowed to play their part, in practising zero tolerance to poor and dangerous care.

“As with every other area in life, providing healthcare is not risk-free and it never will be; the art and science of medicine is in balancing those risks.  But we must create an urgent shift towards a more open and transparent approach that values learning from mistakes and puts the patient experience at the centre of our thoughts and reflections.

“A system obsessed with top-down targets leads to extreme pressure and a bullying culture, and there is a risk that basic clinical care is lost sight of in the race to meet deadlines.”

1.42pm A response from the Foundation trust Network.

Chief executive Chris Hopson extended the FTN’s sympathies to the patients and families affected. He said: “The evidence shows that incidents like those reported at Mid Staffordshire Foundation Trust where failures were so serious, so protracted and had such a devastating and widespread patient impact are rare and isolated.

“It is clear, however, that pockets of poor care do exist right the way across the NHS. Hopefully the Francis report will now help us get to the nub of why poor care continues despite persistent attempts by trusts to resolve this complex problem. Trust boards, commissioners, regulators and staff need to work together to create a culture where patients and their voices are truly at the heart of the NHS.”

1.35pm More responses: National Voices say the Francis report is strong on candour, but weak on patient voice.

Jeremy Taylor, chief executive of National Voices, said: “Patients and their families deserve a legal duty of candour, that’s a real duty to be honest with patients when things go wrong. It is disappointing that the Prime Minister didn’t commit to making this happen in his response to Francis’ recommendations today.

“We also need a much stronger voice for patients and we need to understand how the system will respond to the experiences of patients. Francis’ recommendations could be read as making a paternalistic system stronger, for example with more consultation with patients and communities. That means patients are still responding to the system from the outside. We must go further in building patient leadership, with a seat at the boardroom table and an equal voice with clinicians and managers. And we need managers to develop systems of feedback that are comprehensive, working at all levels of the system and enabling staff to respond quickly.”

National Voices is a coalition of 130 health and social care charities.

1.32pm The Unite union is still baying for blood - Sir David Nicholson’s, to be precise, despite there being little direct criticism of him in Robert Francis’s report.

National officer for health Rachael Maskell said: “A complete overhaul of dysfunctional management in the NHS needs to happen as a matter of urgency and the first person out the door should be Sir David Nicolson, chief executive of the NHS Commissioning Board – perhaps, the most powerful person in the coalition’s new NHS.

“In 2005, he was the regional NHS official who had the oversight of Mid-Staffs when the clinical failures were taking place. Later, as a NHS chief executive, he had accountability as to how the NHS responded as the scandal unfolded.

“The words ‘buck’, ‘stopping’ and ‘here’ have a certain resonance. The recommendations of the Francis Report make his position untenable.”

1.30pm The Health Select Committee is to hold two post-Francis evidence sessions. The first, on 12 February, will be with Robert Francis himself. The second, on 5 March, will be with NHS chief executive Sir David Nicholson.

1.25pm Professor Norman Williams, president of the Royal College of Surgeons has responded: “I’m profoundly sorry for what those patients and their families went through and that they bore such abysmal treatment at the hands of healthcare staff.

“We welcome today’s publication for highlighting, the wider issues of leadership, compassion and the delivery of safe care.”

He says that since the scandal became public, the college has “significantly strengthened” its “invited review mechanism”, which it provides to a trust that wants independent advice on any surgical concerns it has.

“This early form of peer review can help resolve problems before they become insurmountable, and helps hospitals improve team performance and avoid harm to patients,” Professor Williams says.

“We are now preparing for the publication of surgeons’ results later this year and welcome the report’s commitment to the publication of proper outcome data which is publically funded.

“The surgical profession believes this will help reduce mortality rates through greater scrutiny, drive down poor performance and ultimately empower patients.”

But, he adds: “We are still concerned about a zealous pursuit of targets in some trusts to the detriment of quality of care, particularly around the focus on elective procedures in preference to urgent or emergency work.

“There is also fragmentation of care, as patients will sometimes see four or five doctors in a day due to the rules on working hours and shift patterns. We look forward to the government helping to overcome this issue and ensure that there is greater continuity of care and less disruption.”

1.14pm The Royal College of Nursing’s response has arrived. Although the college pledges to look at all 290 of the Francis recommendations, it does not directly address the one which says they should look at splitting their trade union and professional body roles. There’s no word on the “inherent conflict” Francis says exists between their two functions, and nothing so far on the college’s failure to provde “effective support or representation” to Mid Staffordshire nurses.

Chief executive and general secretary, Dr Peter Carter, said: “The RCN welcomes this powerful and monumental report which puts patients at the heart of NHS care. It delivers key recommendations which we support and have been calling for including the registration and regulation of health care assistants. We welcome moves for overarching standards which enshrine what patients deserve from the NHS and from those who work for it.

“Appalling care cannot be tolerated and everything should be done to ensure that it does not happen again. The RCN will now look in detail at each of today’s recommendations and will work closely with the Government, regulators and NHS managers to ensure Robert Francis’ vision for a patient centred NHS becomes a reality.

“The RCN has consistently called for the regulation of health care assistants for the benefit of patients in all care settings including older people’s care. We also welcome a greater call for whistleblowing from staff across the NHS. We have been clear to our members; if they see any examples of poor care they have a responsibility to raise them. This goes hand in hand with greater protection for whistleblowers.

“The RCN is acutely aware that it has real lessons to learn from how it supported members locally at Mid Staffs. Although we have already put in place numerous measures, we will look at the report in depth to see what other steps we can take to improve our effectiveness.”

1.09pm More responses are rolling in. Health Select Committee chair Stephen Dorrell says: “The key to high care standards will always be the commitment and professionalism of the clinical staff.

“Management objectives are important, but they can never be allowed to become an excuse for poor care.

“Robert Francis has made nearly 300 recommendations which need to be carefully considered, but they are all motivated by a desire – as he said in his statement – to avoid creating scapegoats and recognise the importance of strengthening personal and collective accountability within the NHS for the standards of care provided.

“Among his recommendations is the proposal that the Health Committee of the House of Commons should monitor the application of his recommendations by the professional regulators. We shall certainly be following up that recommendation.”

1.08pm Another HSJ news story: An institutional culture which put the “business of the system ahead of patients” is to blame for the failings surrounding Mid Staffordshire Foundation Trust, Robert Francis QC has said.

Announcing the publication of his three volume report into the Mid Staffordshire Foundation Trust Public Inquiry Mr Francis described what happened as a “total system failure”.

12.59pm The Francis report recommends the National Institute for Health and Clinical Excellence draw up guidelines for ward skill mix and minimum staffing levels. These should include measures “not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations.

“The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff.

“These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.”

12.51pm Tricia Hart, currently acting chief executive and director of nursing and patient safety at South Tees Hospitals NHS Foundation Trust, will be brought in to look into complaints handling.

12.49pm Prime Minister David Cameron has asked Bruce Keogh to conduct a review of all hospitals with high mortality rates.

12.49pm The chief inspector of hospitals will be created by the CQC, Cameron says. A new system of hospital regulation will begin in the autumn.

12.48pm David Cameron: We will sweep away the Nursing and Midwifery Council’s “outdated” decision making process.

12.47pm Cameron announces he’s bringing in Don Berwick, who advised Obama, to see how “zero harm” could work in the NHS.

12.46pm Cameron suggests pay for clinical staff should be linked to the quality of care they give, not just the amount of time they’ve been in post.

12.43pm Where quality of care fails, boards could be suspended, says Cameron. Bed sores, he adds, should not be seen as “occupational hazards”. He calls for a “zero harm” approach.

12.42pm Cameron contrasts the consequences for boards of financial failure with those for care failure.

12.41pm Cameron: “I would like to apologies to the families of all those who suffered.”

12.40pm “Managers were surpressing inconvenient facts”, says Mr Cameron. “This was one of the most disturbing findings.”

12.40pm David Cameron: “Francis does not blame any specific policy, or the last Secretary of State for health, and says we should not seek scapegoats.” Odd, as the last secretary of state was Andrew Lansley, who was not in post during the care failings.

12.37pm The PM is on his feet now. Stay tuned…

12.36pm While we wait for David Cameron’s statement, here’s the response from NHS Clinical Commissioners, the collective independent voice of clinical commissioning groups.

The report makes “uncomfortable reading for anybody who works in the NHS”, the statement said. “It is clear that there is a collective responsibility to ensure that failures such as happened at Mid Staffordshire NHS Trust do not happen again.

“As the leaders within CCGs we recognise that quality is the personal responsibility of all who work in the NHS and we cannot delegate that responsibility to anybody else.

“We will use the levers available to CCGs through the commissioning process, clinical engagement and public involvement to drive up quality. We will also use our relationship through that process with providers to ensure and be assured about quality and outcomes. We will also explore and address unwarranted variation.”

The statement continues: “Most of all we will use the intelligence we have, both hard and soft: incident reports, trends, patient feedback as well as data published by providers to shine a spotlight, address failures and use our position to drive up quality throughout the system.”

12.31pm The Prime Minister’s statement on Mid Staffordshire is due to start any moment now.

12.30pm The Royal College of Midwives has released its response. Chief executive Cathy Warwick said: “The recommendation to introduce a new duty of candour is an excellent suggestion.

“We hear far too often from midwives who are genuinely petrified about raising the alarm bell over poor quality of care. They fear that senior managers will come down on them hard simply for raising concerns. We need to transform the culture of the NHS so that midwives and others who need to raise concerns feel happy and secure in doing so.”

She also welcomes the “tough new system that will hold senior managers in particular accountable for their actions”.

“The power to disqualify those who prove themselves unfit to manage the NHS is a massive step forward and matches the rules that currently apply to midwives and are being rolled out to doctors.”

She also welcomed a recommendation for NICE to set minimum safe staffing levels. “For too long the NHS in England has been thousands of midwives short, and we are at the edge of safe care.”

“It is also good to see Francis recommend the regulation of health care assistants,” she added.

12.23pm No official response yet from the NHS Commissioning Board. So far, there’s only been this tweet: “The NHS CB welcome publication of the #francis report and will be issuing a response later today.”

12.19pm One more full story from HSJ - NHS faces new laws on honesty.

12.14pm The Francis report is damning about the Royal College of Nursing. Robert Francis has described the RCN as “ineffective” both as a professional organisation and as a trade union, and it should consider separating its two roles.

12.12pm HSJ’s Sarah Calkin tweeted this from Robert Francis’ statement this morning:

“Francis statement started: we need a patient centred culture

“A failure of the NHS system at every level

“An institutional culture in which the business of the system was put ahead of patients to blame for #MidStaffs says #Francis

“Causing death or harm through non compliance with essential standards should be a criminal offence

“#Francis calls for new registered role of registered older persons’ nurse

“It’s the responsibility of everyone in the NHS to bring these improvements about #Francis. And he’s gone.”

12.09pm The Francis report is 1,919 pages long, if you include the executive summary, HSJ’s editor Alastair McLellan tweets.

12.08pm The Francis report has recommended revalidation for nurses. The report calls for the Department of Health and the NMC to develop the idea of a Responsible Officer for Nursing, and for a system of annual revalidation similar to doctors to be created. Nurses would have to demonstrate key skills and knowledge and include feedback from patients.

11.59am The #Francis hashtag is currently the number two trend on Twitter in the UK.

11.58am Law firm Kingsley Napley LLP, who represented Action against Medical Accidents and the Patients Association, patient charities invited to take part as core participants in the Mid Staffordshire NHS Trust inquiry, have issued their reaction to Francis. They warn the whole thing could turn out to be a waste of time unless the government act.

Emily Carter, public law partner said: “The challenge for Mr Francis has been to identify recommendations which will translate into real improvements. The challenge for the government is now to effectively incorporate these £13m recommendations into policy. However, under the inquiry system there is no obligation to do so. In our view, there is a very real risk that Mr Francis’ careful examination of the causes of one of the most appalling failings in NHS history will be little more than a time-consuming and expensive white elephant.

“Yet remedial action is the very least the thousands of affected families and whistleblowers deserve.

“In the months and years to come, Mr Hunt’s good intentions should be tested by evaluating concrete action against the full list of Mr Francis’ recommendations.”  

11.54am Former Andrew Lansley special advisor Bill Morgan tweets that Francis’ recommendation to take on Monitor’s responsibilities for “corporate governance” and “financial competence” would leave Monitor with the sole job of economic regulation. “As it always should’ve been,” he says.

11.51am The reponses have started coming in. The NHS Alliance says: “It may be tempting to call for more rules and stronger regulation to ensure that this never happens again.  But at the heart of the failure at Mid Staffordshire was a culture where people felt unable or unwilling to challenge what was going on, and to ensure that caring for people and making sure that they are safe is always placed above finances. There will need to be a cultural change, with a new emphasis on the power of the patient voice.” 

11.44am Full HSJ stories on the findings of the Francis report are now live on our Francis report page.

Francis stops short of statutory regulation for managers

Francis calls for beefed up CQC as single regulator

Francis avoids direct criticism of top NHS leaders

Francis report: HCAs will face regulation

11.40am All three volumes of the Francis report can now be downloaded from the inquiry’s official website.

11.35am The Francis report has criticised the work of the strategic health authorities which oversaw Mid Staffordshire Foundation Trust, but includes little direct criticism of specific leaders, including Sir David Nicholson.

Sir David, now NHS chief executive, was chief executive of Shropshire and Staffordshire Strategic Health Authority, which oversaw the Mid Staffordshire Trust, from August 2005. He was the lead officer ahead of the creation of the new West Midlands SHA until 2006 when he took over at NHS London before becoming chief executive of the NHS in September that year.

He has faced calls for his resignation in recent weeks, including from Julie Bailey, who leads the campaign group Cure the NHS.

The Francis report says, specifically of West Midlands SHA, but also related to the work of its predecessors: “The SHA made no link between its roles in relation to finance and workforce and how these may impact on patient and care quality – it prioritised targets and not patients and focused on finance not quality.”

However, the report includes no direct criticism of Sir David’s role.

11.32am The Francis report has recommended there should be a series of new laws requiring all NHS staff and directors to be open and honest when mistakes happen.

This would include a new power for the Care Quality Commission to prosecute organisations and individuals who break the rules.

Robert Francis has called for a statutory duty of candour to be imposed on NHS directors to be “truthful” with information they give to healthcare regulators.

He has also called for a change in the law to impose a duty of candour on all doctors, nurses and registered professionals to admit mistakes which have caused “death or serious injury” to their employer as soon as possible.

All healthcare providers should also be required by law to inform the patient or relatives of the mistake and provide information to them.

11.32am Healthcare support workers should be subject to regulation by the Nursing and Midwifery Council, the Francis report has recommended.

Robert Francis said HCAs should not allowed to deliver personal care to patients in any healthcare setting without first being registered.

He has also demanded a national code of conduct and a national set of standards for training of HCAs who he said should also be clearly identified and distinguishable from a registered nurse.

11.31am Directors of NHS providers should be subject to a new “fit and proper person” test, Robert Francis QC has said.

The Francis report recommends consideration should be given to whether a person has to have a minimum level of experience and/or training to be considered a fit and proper person.

Martin Yeates, chief executive of Mid Staffordshire Foundation Trust during most of the period covered by the inquiry was in his first chief executive role.

Recommendation 82 of 290 states: “Provision should be made for regulatory intervention to require removal or suspension from office after due process of a person whom the regulator is satisfies is not or is no longer a fit and proper person, regardless of whether the trust is in significant breach of its authorisation or licence.”

11.30am The Francis report has recommended a single regulator for the NHS.

The Care Quality Commission should take on responsibility for “corporate governance” and “financial competence” alongside quality, following a merger with the CQC.

Mr Francis has warned  ministers to “avoid the temptation” of abolishing both regulators and starting again.



A quick recap before the Francis report goes live:

  • The report will be out at 11.30am
  • Prime Minister David Cameron will make a statement to Parliament at 12.30pm
  • Reports in the national dailies suggest that there will be a statutory duty of candour to report failings in care.
  • There are also suggestions that ministers will bring in a chief inspector of hospitals
  • Many will be anxious to see what the report has to say about NHS chief executive Sir David Nicholson, who led Shropshire and Staffordshire strategic health authority while care standards were failing at Mid Staffordshire.

11.10am HSJ’s acute sector reporter Ben Clover tweets: “If #Francis blames cost-cutting programmes, quick fact: Hospital trusts aiming to cut costs by £2.35bn this year.” For further reading, see his story here.

“We’re going to hear lots of guff abt targets being intrinsically bad,” he adds. “Some things more measrble than others.”

11.07am Here’s the Mid Staffordshire inquiry page. The report should be there in less than 25 minutes.

11.05am Shaun Lintern - before the media lockdown began, we should add - tweeted this picture from the Francis inquiry launch. Each one of those boxes contains a copy of the report - it’s going to be lengthy document indeed.

11.00am Kieran Walshe, professor of health policy and management at the Manchester Business School, has been tweeting some of the findings of a public inquiry into Ely Hospital, from 1969.

Some of the findings will be depressingly familiar to anyone with even a basic knowledge of what happened at Mid Staffordshire.

Kieran tweets: “Ely Hosp 1969 “An unduly casual attitude towards sudden death [and] inadequate systems for reporting incidents” #Francis

“Ely “..nursing staff [felt] it was almost more than their professional life was worth for them to voice any feelings of concern.” #Francis

“Ely 1969 “A structure of ..administration which has resulted in virtual isolation… in a close knit and inward looking community.” #Francis

And so on, and so on.

He concludes: “So the question really is: after about 30+ inquiry reports on NHS failures in care, what will be different after #Francis?”

10.54am Here’s the Department of Health’s page on Mid Staffordshire. Doesn’t say much, but has links to the Parliament TV page where you can watch the debate in the House of Commons from 12.30, and to the official Mid Staffordshire inquiry page, where the report will be published.

10.50am Julia Manning, chief executive of the 2020health think tank, has just sent out a press release on Mid Staffordshire. “Professionals need to see patients as equals,” she writes. “Intimidation and arrogance is intolerable - and they should welcome involvement, be it as volunteers onto wards or supporting advocacy roles for other patients.

“Transparency alone will only deliver manipulation. Accountability to communities and flexibility to respond to local need is a necessary precursor to changing attitudes.”

Echoing a “senior government source” who appears to have briefed the Telegraph today, she adds: “You can’t legislate for compassion; we all need to have greater respect for the role of caring and the elderly, and be prepared to take responsibility.

“Ultimately clinicians and managers at all levels need to accept – must be made to accept – that when things go wrong, the right response is to humbly sit down with those involved, talk through the issue and apologise.”

10.44am HSJ reporters Dave West, Sarah Calkin and Shaun Lintern are now in the lock-in for media to read theFrancis report. In his last tweet before publication, Shaun said: “Radio silence until 11.30. Rumours of 100+ recommendations.”

10.36am Another line from the Daily Mail story today - “Whitehall sources said the report would identify a culture of ‘metrics and league tables’ in the way hospitals are judged as a key factor in the scandal.” It will be interesting to see how that squares with ministers’ commitments to Ofsted style ratings for hospitals, a new chief inspector of hospitals, and more open publication of trust performance data.

10.23am HSJ has a page devoted to its coverage of the Francis inquiry. Bookmark it today, we’ll be posting new stories up here regularly.

10.21am This came out yesterday evening, but in case you haven’t seen it yet: Here’s an HSJ podcast on Mid Staffordshire. Reporter David Williams talks to colleague Shaun Lintern about the wider importance of the scandal, and his experiences covering - and giving evidence to - the inquiry.

10.17am BBC Radio 4’s flagship Today programme devoted its most prestigious slot to the Mid Staffordshire scandal this morning, focusing on the stories of clinical staff who felt unable to raise concerns about the quality of care. You can listen back to their package here.

10.13am The Financial Times reports this morning that the Francis Inquiry’s findings “could put a question mark over the future” of NHS Commissioning Board chief executive David Nicholson.

“However,” the paper adds, “Whitehall officials yesterday sidestepped suggestions that the findings could cost Sir David his job, saying that [health secretary Jeremy] Hunt – who against some expectations, was cleared of bias in the British Sky Broadcasting bid by Lord Justice Leveson – had good reason to be wary of pre-judging the findings of an official report.”

10.12am Nursing Times editor Jenni Middleton was on Five Live this morning discussing the Francis report. You can hear her here, about 3 minutes and 40 seconds in.

10.10am The Guardian has also gone with the line about the expected recommendation for a duty of candour. Their coverage is fairly low profile this morning, but also includes an opinion piece by health correspondent Denis Campbell. “But patient safety experts… fear that staff shortages, money pressures and rising demand mean that one is more likely now, not less. Let us hope Robert Francis is not needed again.”

10.01am In case you hadn’t seen it - here’s that story on former Mid Staffordshire head nurse Helen Moss, who held the role from December 2006, resigning in late 2009.

HSJ’s sister title Nursing Times has learnt she has been cleared by an investigating committee at the NMC, which has deemed there was “no case to answer”.

9.55am The Times doesn’t have much on Mid Staffordshire just a short lead on page eight following up the story from yesterday that the nursing and midwifery council has cleared the trust’s former nursing director.

9.51am Mary Riddell, writing in the Telegraph, points out that the Mid Staffordshire scandal could be a political opportunity for Labour. She argues that the report’s expected description of systemic failings in the NHS could help shadow health secretary Andy Burnham make the argument for wholesale integration of NHS and social care services.

9.45am The Daily Telegraph is reporting that the Francis enquiry will recommend a statutory duty of candour on medical staff to flag up concerns about the quality of care. “NHS hospitals should face prosecution if doctors and nurses fail to blow the whistle,” their story says.

9.41am Sarah Calkin tweets: “On face of it chief inspector of hospitals fits fairly well with CQC plans for different approaches to reg hospitals & care homes”.

9.38am Phil Hammond, who exposed the Bristol heart scandal in Private Eye, has written a piece on Francis for HSJ. He fears many of the Kennedy inquiry’s recommendations will be repeated by Robert Francis and that they arrive too late. Read in full here.

9.13am Much comment on Twitter about Francis:

@Jon_Restell: “Some will be defensive, some tribal, some ideological. The best will be open-hearted & embrace #Francis to change our culture.”

@ShaunLintern [from the inquiry]: “Families and witnesses have gone inside. Journalists still waiting to go in. #Francis |
@JeremyTaylorNV “Chief inspector of hospitals? I have my more faith in listening to patients, families & staff.”
@cpeedell “With Payment by Results system, everyone is terrified of releasing poor outcome data, because income streams will collapse.”

9.07am Here’s a bit more on the new chief inspector of hospitals role from the Daily Mail:

“The Prime Minister will respond to the findings by announcing the creation of a new chief inspector of hospitals, who will be charged with ensuring hospitals deliver good, compassionate care rather than simply ‘chasing targets’.

“Mr Cameron is expected to say: ‘We need a hospital inspection regime that doesn’t just look at numeric targets, but makes a judgment about the quality of care.’

“The system will be modelled on that introduced in the early 1990s in education, where a chief inspector sends regular inspection squads into classrooms to assess all aspects of school life.”

7.45am The Sun is reporting that prime minister David Cameron is planning to announce a new chief inspector for hospitals when he responds to the Francis report later today. The inspector will be tasked with “rooting out degrading patient care” and will have “sweeping powers to check hospitals and reprimand failing doctors”, the paper says.

7.32am Today sees the publication of the Francis report into care failings at Mid Staffordshire Foundation Trust. The report, which comes out at 11.30am today, is the product of a public inquiry into systemic failings of care between 2005 and 2009. Robert Francis QC, who conducted the inquiry, heard evidence of widespread substandard care from clinical staff, along with systemic failings that went right to the top of the NHS and Department of Health.

Although many senior health policy figures are under scrutiny, there will be particular attention paid to what the report says about Sir David Nicholson. The NHS Commissioning Board chief executive was at the time the head of the Shropshire and Staffordshire strategic health authority, and has faced calls to resign over his part in the scandal.

Shaun Lintern, who reported on the inquiry as a local journalist before moving to HSJ, has written this piece about the five years he has spent on the story. Shaun attended the vast majority of the inquiry’s evidence sessions and also gave evidence.

He’s also produced this Francis report myth-buster to clear up commonly-held misconceptions about the affair.