Five years ago this morning, the NHS held its breath ahead of the publication of Robert Francis QC’s landmark report into the Mid Staffordshire care scandal.
Mr Francis’ (now Sir Robert’s) inquiry had lasted more than two years, taken evidence from more than 350 witnesses, and cost more than £19m.
His report laid bare the appalling suffering and neglect of hundreds of patients over many years who were “failed by a system which ignored the warning signs and put corporate self interest and cost control ahead of patients and their safety”.
Five years on, where are we now? Have we achieved the patient centred culture that was missing? Are we better at recognising and responding to concerns? As so often in the NHS, the answer is not simple.
The Care Quality Commission has been transformed and works under statutory fundamental standards of care, with tougher penalties for trusts which fall below them. This was one significant move post Francis.
It is debatable, though, whether the inspectorate is as willing as it should be to act to enforce these standards. Its handling of the fit and proper person test is particularly woeful – illustrated by some especially high profile lapses.
One of the key issues from Francis was transparency of board discussions on safety and quality.
Staffing data is now public and boards regularly discuss ward by ward data in a way which was never the case pre-Mid Staffs.
But Sir Robert has been clear there is more to do. He told the Commons health committee recently: “Trusts’ planned staffing numbers figures are expected to be derived from ‘evidence based tools’ as to which there is no standard to be met.
“The figure may well represent that which the provider’s board has accepted as safe, but there is no measure as to whether this is in fact the case.”
Sticking with workforce, the suspension in 2015 of work by the National Institute of Health and Care Excellence to set evidence based safe staffing rules was a singular failure by the Department of Health and Social Care and NHS England.
But the 40,000 nursing vacancies now being reported by trusts – despite record recruitment levels – is a sign the service is being far more honest about the levels needed.
New research suggests the Francis report has changed conversations at the senior level in trusts, and that a new legal duty of candour has made it easier for staff and hospitals to be honest with patients about mistakes.
But researchers warned this progress was fragile and at risk from financial pressures and top down burdens.
There are still too many examples of secrecy, often stemming from the approach of national NHS agencies and the DHSC. This is strikingly reminiscent of lessons from Mid Staffs.
Elsewhere, one of Sir Robert’s recommendations which was rejected by the government was to make it a criminal offence to obstruct another member of staff from raising genuine concerns. This was aimed at protecting whistleblowers on the frontline.
In the years since Francis, we have seen many attempts to address this complex issue – but most appear to have had limited effect. Whistleblowing remains an area for further work.
Equally, on the NHS complaints system there is still much unfinished business.
The public inquiry recommended commissioners should be allowed to intervene in the management of an individual complaint if it was not being properly dealt with. That has not been implemented, and this source of much anguish for families has gone unresolved. A review by Ann Clwyd MP and Tricia Hart in 2013 quickly faded into history.
Sir Robert added his voice to calls for a new independent medical examiner service, with doctors independently reviewing all deaths and liaising with bereaved families about which deaths should go to coroners. They have been proven to contribute to the safety of the living as well as the dead. The government has made warm noises about this, but has yet to put forward proposals after a consultation and local councils remain in the dark about the service they should be providing in theory from April next year.
Regulation of healthcare assistants remains an unsatisfactory gap - with pub bouncers, taxi drivers and nursery staff subject to more scrutiny than those dealing with our most vulnerable patients.
The HCA care certificate remains voluntary. The nursing associate role which is under development could potentially provide a new foundation for care staff - but instead sadly seems to be aimed at down skilling registered nursing.
David Cameron, with Jeremy Hunt at his side, pledged to reform professional regulation back in 2013 to bring it up to date.
There has been a Law Commission report and minor tweaks, but this remains a significant area requiring further work – particularly Sir Robert’s call for bodies including the medical and nursing regulators to take a systematic view of failures.
The inquiry recommended regular annual update reports by the DHSC - it perhaps says something that this was allowed to lapse after only one year.
The NHS is now in the grip of the tightest spending settlement in its history, amid ever rising demand.
NHS England is driving forward the agenda of new care models and a renewed focus on system form – accountable care systems, accountable care organisations, sustainability and transformation partnerships and integrated care systems now dominate discussions.
These are purported to be about patient care, but the conversations feel reminiscent of the focus on foundation trust status, circa 2006.
The distractions are there to take people’s eye off patient care – meaning the ingredients exist for a repeat of Mid Staffs.
The progress made since Francis has lessened the risk, but isn’t sufficient. The one real safety net is the CQC - but its effectiveness is being degraded by system pressure and cuts to its own budget.
The other thing standing in the way of another care disaster is the NHS workforce: Another Mid Staffs is not inevitable, it can be prevented. It is up to every NHS leader and member of staff not to forget the painful lesson delivered just five years ago.
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