The Mid Staffordshire NHS Foundation Trust Public Inquiry was announced on 9 June 2010 by the Secretary of State for Health (Andrew Lansley MP).
The Inquiry was established to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry was chaired by Robert Francis QC and considered why the serious problems at the Trust were not identified and acted on sooner and draw lessons to be learnt for the future of patient care.
The final report of the Inquiry was published on Wednesday 6 February 2013.
The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust provides detailed and systematic analysis of what contributed to the failings in care at the trust. It recognises that what happened in Mid Staffs was a system failure, as well as a failure of the organisation itself. Rather than proposing a significant reorganisation of the system, the report concludes that a fundamental change in culture is required to prevent this system failure from happening again, and that many of the changes can be implemented within the current system. It stresses the importance of avoiding a blame culture, and proposes that the NHS – collectively and individually –adopt a learning culture aligned first and foremost with the needs and care of patients.
The report identifies that the failures of the Trust was primarily caused by a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.
The report says ‘The story would be bad enough if it ended there, but it did not. The NHS system includes many checks and balances which should have prevented serious systemic failure of this sort. There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care. For years that did not occur, and even after the start of the Healthcare Commission investigation, conducted because of the realisation that there was serious cause for concern, patients were, in my view, left at risk with inadequate intervention until after the completion of that investigation a year later. In short, a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system’.
The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. That they did not has a number of causes, among them:
- A culture focused on doing the system’s business – not that of the patients;
- An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern;
- Standards and methods of measuring compliance which did not focus on the effect of a service on patients;
- Too great a degree of tolerance of poor standards and of risk to patients;
- A failure of communication between the many agencies to share their knowledge of concerns;
- Assumptions that monitoring, performance management or intervention was the responsibility of someone else;
- A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession;
- A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.
The Francis report makes 290 recommendations along the following themes:
1. Foster a common culture shared by all in the service of putting the pt first;
2. Develop fundamental standards and measures of compliance:
- Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff
- Provide professionally endorsed and evidence based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service;
- Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards. Non-compliance with these standards should not be tolerated and any organisation not able to consistently comply should be prevented from continuing a service which exposes a patient to risk
- To cause death or serious harm to a patient by non-compliance without reasonable excuse of the fundamental standards, should be a criminal offence.
- These fundamental standards should be policed by the Care quality commission (CQC)
- The merger of the regulation of care into one body – with Monitor responsibilities being absorbed by the CQC over time
3. Ensure openness, transparency and candour throughout the system underpinned by statute. Without this a common culture of being open and honest with patients and regulators will not spread. Including:
- The “ duty of candour” – a statutory duty to be truthful to patients where harm has or may have been caused
- Staff to be obliged by statute to make their employers aware of incidents in which harm has been or may have been caused to a patient
- Trusts have to be open and honest in their quality accounts describing their faults as well as their successes
- The deliberate obstruction of the performance of these duties and the deliberate deception of patients and the public should be a criminal offence
- It should be a criminal offence for the directors of Trusts to give deliberately misleading information to the public and the regulators
- The CQC should be responsible for policing these obligations
4. Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do;
a. Improved support for compassionate, caring and committed nursing
- Entrants to the nursing profession should be assessed for their aptitude to deliver and lead proper care, and their ability to commit themselves to the welfare of patients
- Training standards need to be created to ensure that qualified nurses are competent to deliver compassionate care to a consistent standard
- Nurses need a stronger voice, including representation in organisational leadership and the encouragement of nursing leadership at ward level
- Healthcare workers should be regulated by a registration scheme, preventing those who should not be entrusted with the care of patients from being employed to do so.
b. Stronger healthcare leadership
- The establishment of an NHS leadership college, offering all potential and current leaders the chance to share in a common form of training to exemplify and implement a common culture, code of ethics and conduct
- It should be possible to disqualify those guilty of serious breaches of the code of conduct or otherwise found unfit from eligibility for leadership posts
- A registration scheme and a requirement need to be established that only fit and proper persons are eligible to be directors of NHS organisations.
So in summary, Francis report recommends making all those who provide care for patients – individuals and organisations – properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service. It also recommends development and sharing of ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.
What is integrated care?
Integrated care means care which is organised around the needs of individual patients. . Integrated care is not about structures, organisations or pathways – it is about better outcomes for service users.
There is now a clear consensus that successful integrated care is primarily about patient experience, although all dimensions of quality and cost-effectiveness are relevant
Further, integrated care is clearly not an end in itself, but is an essential tool to improve outcomes for individuals and communities.
In order to show why a smooth journey through the NHS is desirable, it is important to understand what a non-integrated system looks like and the experience that service users face when navigating through a fragmented system. For e.g. a diabetic patient may need services of the following: cardiology team, GP, practice nurse, renal team, diabetic team, diabetes specialist nurse, GP, practice nurse, vascular team, foot team, eye team, retinal screening team etc. This illustrates the complexity service users must navigate and, therefore, highlight the need of a more integrated system.
What are the problems with the current non- integrated care system?
- Lack of ‘ownership’ for the patient and her problems, so that information gets lost as she navigates the system
- Lack of involvement by the user/patient in the management and strategy of care
- Poor communication with the user/patient as well as between health and social care providers
- Treating service users for one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment
- Lack of integration between health and social care- although decisions made in the social care setting affect the impact of health care treatment, and vice versa.
Is integrated care really needed?
The NHS is faced with the major challenges of using resources more efficiently and of meeting the needs of an ageing population in which chronic medical conditions are increasingly prevalent. The key task therefore is to implement a new model of care in which clinicians work together more closely to meet the needs of patients and to co-ordinate services and enable people with complex needs to live healthy, fulfilling, independent lives.
This model of integrated care would focus much more on preventing ill health, supporting self-care, enhancing primary care, providing care in people’s homes and the community, and increasing co-ordination between primary care teams and specialists and between health and social care
Integrated care is the only way to make health system sustainable in the long term by transferring care out of expensive hospitals and nursing homes in the community or even in patients own home.
What are the aims of integrated care?
- Improved patient experience- by providing a seamless service reducing gaps and duplication in service
- Improved patient outcomes i.e. improved quality
- Improved cost effectiveness of care by improving system efficiency
- Better experience for medical staff
However it is important to point out that more integrated care is not always the right answer to improving the patient’s experience and system efficiency. Integrated care also carries some risks, such as that of reducing competition, and incentives to improve quality.
How would you develop integrated care?
- There are no general rules
- Benefits depend on the specific design and approach to integrated care based on local circumstances
- Learn from successful examples
- Take patients view into account
Successful integration depend on which approach is used, how well it is implemented, and on features of the environment in which a provider is operating, including the financing system.
What are the barriers to integration?
- Organisational boundaries- Primary or community care and secondary care or hospital care, social care (provided by LA) and health care- making it difficult for services to be properly coordinated. This leads to gaps and duplication of services. In a fully integrated system, patients’ needs not organisational boundaries would decide how care is provided
- Lack of shared record keeping about a patient (GPs, hospital, nurses, social care workers)- hence patient and carers end up telling the same story to healthcare professionals. Lack of this info also cause poor care for e.g. a patient may turn up in ED and lack of info would not help
There are other barriers like:
- Payment by Results provides hospitals with some incentives to keep patients in hospital rather than treating them in the community.
- Service users choosing alternative providers: service users have freedom of choice regarding their elected place of care. However, this freedom can create deviations from the planned pathway of care and may cut across attempts to provide integrated care.
How can organisations enable integrated care?
Several measures could potentially mitigate these barriers. They may include:
- Personal budgets
- Make it easier for service users and carers to coordinate and navigate. This implies that every service user with long‐term or complex needs has easy access to a “care coordinator”, or federations of GP practices who can act as the coordinating point for all of their care.
- Information is a key enabler of integrated care. Care records should be electronic and accessible at the point of care throughout the whole care journey, regardless of sector or provider
Can we do it?
NHS has spent the last decade or more in ensuring faster and easier access to GPs and consultants; reducing waiting times etc. and indeed vast progress has been made in these areas.
This was made to matter to the managers and clinical leaders- we need the same focus- the same urgency and importance being attached to patients with long term conditions, frail older people- and only when it matters that integrated care will become a reality.
What can we do to facilitate integrated care?
- Clear policy directive as to why integrated care is important- we spend too much in acute hospitals, care to individual patient is poor and if we don’t change the system- it will never become a sustainable system
- Sustained support for people seeking to develop integrated care locally- support in the form of using data analysing population need, project management,
- Evaluation of integrated care initiatives- so that we can learn
To me it means that things are joined up, not fragmented into different parts with no one person informing all the relevant agencies about your needs and condition. Importantly also integrated care must include the persons wishes and needs, too often at the moment the person is left out of the loop! In my experience I am ‘told’ what I can and can’t have regardless of my needs and wishes. This is the same for many unfortunately.
Increasing number of trusts is employing psychometric tests as part of consultant recruitment process.
What is the purpose of psychometric tests?
These tests (sometimes known as personality profiling) are used to assess ability, performance and behaviour of the candidate. These tests can provide an insight into assess personal qualities, such as personality, beliefs, social competence, values and interests and to measure motivation or drive.
They are used to provide employers with a reliable method of selecting the most suitable job applicants or candidates for the job advertised.
How is psychometric test conducted?
The test generally consists of a series of multiple choice questions. Questions focus on specific traits of the individual’s personality.
The questionnaire is subsequently assessed by a psychologist or other trained assessor. The questionnaire may also be followed by an interview with a psychologist/trained assessor to validate the results further.
How do psychometric test results impact on consultant recruitment?
The tests provide additional useful information to inform the final selection of the candidate. The test results may be used in the interview to guide specific questions.
These tests are not about passing or failing but about giving a profile of the candidate to the employer, whose task it is to match an applicant to the job or work place.
Can you prepare for the psychometric test?
No, because there are no right or wrong answers. Further, each department look for specific personality traits in the candidates and trying to second guess the answers may be counter- productive.
Tip: Try and provide honest answers rather than perceived best answer lest you come across as inconsistent.
The Health and Social Care Bill overcame its last hurdle after passing through the Houses of Lords and Commons and has received Royal Assent . There has clearly been much difference of opinion and debate regarding the content and potential impact of the Bill.
An updated NHS Constitution was published on 8th March 2012. The new version of the Constitution, which applies to England, replaces the previous version of the Constitution published in 2010. There is also an updated handbook to accompany it.
As part of a series of measures intended to highlight the importance of whistleblowing in the NHS, the updated Constitution includes:
- an expectation that staff should raise concerns at the earliest opportunity
- a pledge that NHS organisations should support staff when raising concerns by ensuring their concerns are fully investigated and that there is someone independent, outside of their team, to speak to
- clarity around the existing legal right for staff to raise concerns about safety, malpractice or other wrong doing without suffering any detriment
The hope is that the above change in NHS constitution would make it easier for staff to raise concerns about poor patient care and thus create a culture of patient safety.
The General Medical Council has published new guidance on leadership and management for doctors that spells out their responsibility for the safety and wellbeing of patients when performing non-clinical duties. Leadership and Management for All Doctors, which comes into effect on 12 March, is available on the GMC website at
The guidance sets out the wider management and leadership responsibilities of doctors in the workplace, including in relation to employment issues, teaching and training, planning, using and managing resources, raising and acting on concerns and participating in service improvement and development. The principles in the guidance apply to all doctors regardless of whether they work directly with patients or whether they have a formal management role.
Doctors are still accountable to the GMC for their non-clinical duties, such as their behaviour as a manager, the guidance states.
The guidance states that being a good doctor involves more than simply being a good clinician. It involves commitment to improving the quality of services and to demonstrate leadership in managing and using resources effectively.
Doctors should also respect their colleagues and tackle discrimination where it arises, it adds.
The guidance reinforces that doctors should be prepared to contribute to discussions and decisions about the allocation of resources and the setting of priorities in any organisation in which you work and the commissioning of services for the wider population of patients.
The guidance also contains a section on allocating resources, in particular exploring some of the areas that doctors will need to think about when resources are limited, including:
- Considering the needs of patients AND the wider population.
- Being familiar with local and national policies on access to treatments.
- Making sure that decisions about access to care are based on clinical need and the likely effectiveness of treatments.
- Being honest with patients about then decision making process.
Discuss the new GMC guidance ‘Raising and acting on concerns about patient safety’ (2012)?
The guidance comes into effect on 12 March 2012 and will replace Raising concerns about patient safety (2006). The publication of Raising and acting on concerns about patient safety is especially timely given the recent findings of the Mid Staffordshire enquiry.
Raising and acting on concerns about patient safety (2012) sets out that that all doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity is being compromised.
The guidance is separated into two parts.
Part 1: Raising a concern gives advice on raising a concern that patients might be at risk of serious harm, and on the help and support available to doctors.
Part 2: Acting on a concern explains doctors’ responsibilities when colleagues or others raise concerns with them and how those concerns should be handled.
Part 1: Raising a concern
- All doctors have a duty to raise concerns
- Overcoming obstacles to reporting
You may be reluctant to report a concern for a number of reasons. For example, because you fear that nothing will be done or that raising your concern may cause problems for colleagues; have a negative effect on working relationships; have a negative effect on your career; or result in a complaint about you. If you are hesitating about reporting a concern for these reasons, you should bear the following in mind.
- You have a duty to put patients’ interests first and act to protect them, which overrides personal and professional loyalties.
- The law provides legal protection against victimisation or dismissal for individuals who reveal information to raise genuine concerns and expose malpractice in the workplace.*
- You do not need to wait for proof – you will be able to justify raising a concern if you do so honestly, on the basis of reasonable belief and through appropriate channels, even if you are mistaken.
- Steps to raise a concern
- Local incident reporting systems
- If you have reason to believe that patients are, or may be, at risk of death or serious harm for any reason, you should report your concern to the appropriate person or organisation immediately. Do not delay doing so because you yourself are not in a position to put the matter right.
- Report to the regulatory body (GMC) in the following circumstances: a.If you cannot raise the issue with the responsible person or body locally because you believe them to be part of the problem. b. If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action. c. If there is an immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene
- Making a concern public: You can consider making your concerns public if you: a. have done all you can to deal with any concern by raising it within the organisation in which you work or which you have a contract with, or with the appropriate external body, and b. have good reason to believe that patients are still at risk of harm, and c. do not breach patient confidentiality.
Wherever possible, you should first raise your concern with your manager or an appropriate officer of the organisation you have a contract with or which employs you – such as the consultant in charge of the team, the clinical or medical director or a practice partner. If your concern is about a partner, it may be appropriate to raise it outside the practice – for example, with the medical director or clinical governance lead responsible for your organisation. If you are a doctor in training, it may be appropriate to raise your concerns with a named person in the deanery – for example, the postgraduate dean or director of postgraduate general practice education.
Part 2: Acting on concerns
All doctors have a responsibility to encourage and support a culture in which staff can raise concerns openly and safely. Concerns about patient safety can come from a number of sources, such as patients’ complaints, colleagues’ concerns, critical incident reports and clinical audit. Concerns may be about inadequate premises, equipment, other resources, policies or systems, or the conduct, health or performance of staff or multidisciplinary teams. If you receive this information, you have a responsibility to act on it promptly and professionally. You can do this by putting the matter right (if that is possible), investigating and dealing with the concern locally, or referring serious or repeated incidents or complaints to senior management or the relevant regulatory authority.
Who can help if you are not sure what to do? Answer here