Be careful what you wish for


Norman Warner takes a forensic look at the second Francis Report on the failures of Mid-Staffs

Robert Francis performed an important public service in his first report in 2010. He identified appalling clinical, managerial and governance failures at the Mid-Staffordshire Trust and the inadequate responses of those supervising and regulating that Trust. These inexcusable failures caused, understandably, great pain and anguish to the families of the patients maltreated. But things have changed since 2010 both in Mid-Staffs and the NHS more widely. 

Francis’s second report with nearly 2000 pages long and 290 recommendations seems much more of a curate’s egg than his first. There are nuggets that will help the NHS improve: the call for candour and more transparency deserves our full support, as does identifying Board members and managers who are not fit and proper persons. The Care Quality Commission does need to improve its effectiveness, especially the way it uses the process of registering providers. But across the political spectrum we should see the recommendations as an a la carte menu from which we can select judicially. 

So, in the current febrile atmosphere we should review carefully the strength of the evidence in the second report and its relevance to improving the NHS as it is today. Three key questions seem to require particular attention.

First, is there convincing evidence that the behaviour at Mid-Staffs some time ago is widespread in the NHS?  

In reading the 115-paged executive summary, I found little compelling evidence to support the report’s central argument that the systemic failures relating to one Trust can be regarded as widespread. After a £13 million inquiry I would have expected to be more convinced than I was. 

The explanation may lie in paragraph 104 of the summary, in which Francis acknowledges that new compelling evidence required him to amend his report substantially. Is it possible that things were not as bad as first thought, but it was too late to change direction? I hope the government shares my concern that without appearing complacent we must avoid tarring 1.3 million NHS staff with the same brush – particularly when we know that the NHS’s million daily encounters with patients leaves the overwhelming majority satisfied.

Second is the question of whether concentrating huge efforts on performance management and regulation of hospital care means we fail to see a bigger picture. 

We have known for some time that too many people are in acute hospitals that should not be there, with estimates varying from 25% to 40%. The NHS operating framework identified this problem a while ago, and I have found nothing in the second Francis Report that considers this issue. 

If we now put huge amounts of regulatory, commissioning, clinical and management effort into hospital care, presided over by a new Chief Hospital Inspector, then we are missing a critical point for the future sustainability of the NHS. 100 years ago most people died at home; now over 50% die in hospital. If we really want to hold David Nicholson and his Board to account, we should be concentrating on what they are doing to change the commissioning of services – for which they control most of the funding – so that fewer elderly people are left mouldering in medical wards. That is the real NHS systemic failure.

Third, we should ask whether the answer to failed regulation is more regulation.

New criminal sanctions for staff and board members make little sense, when we already struggle to get good board members for what can be seen as a rather thankless task. Whistleblowers always face being socially ostracised; and will there really be more whistleblowing if staff think they might send a colleague to jail?

We can help the public be their own regulators with a better transparent rating system for hospitals, but also for GPs and community services. More publicly-available standardised comparable data for providers would also help but the government rejected amendments on this during the passage of the Health and Social Care Bill. Francis simply has not made the case for the highly disruptive proposal to merge CQC and Monitor. 

The focus now should be on better staff training (especially of healthcare assistants and nurses); leadership preparation for Boards; more robust disciplinary processes in current professional regulation; better standardised comparable data for the public on the care and performance of NHS providers; and targeted institutional regulation on the weakest performers. 

But what the NHS and its patients do not need at this time of increasing austerity is regulatory saturation bombing and further organisational change. Or a political virility contest on how many of Francis’s 290 recommendations can be ticked off as having been accepted. 

Lord Norman Warner if a backbench Labour Peer in the Lords and a former Health Minister

Published 12th March 2013


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