My hopes (and fears) for how the NHS will respond to the Francis Report into Mid-Staffordshire NHS FT

Robert Francis QC will be publishing his report on the morning of Wednesday 6th February. This hugely important report has been overly delayed and is both much anticipated and much needed. Its findings will have an enormous impact upon the NHS for years to come.
I sincerely hope that it has a dramatic and positive impact upon the NHS but I fear that it has an almost equal potential to be destructive.

Things which are very important, but which I am sure will get ample discussion elsewhere

  • I don’t want to rehash some of the truly outrageous failures of care. If you want a pretty good summary then it is pretty much covered it in this article:
  • Similarly there will inevitably be a lot of coverage about some of the individuals (some with a high profile) involved and their personal responsibility, whether there should be resignations etc. All that will come out in the report, and there is no point in my trying to second guess its recommendations
  • The Francis Report will probably make recommendations with regard to regulatory bodies within the health service and it is best that we await his considered recommendations
  • Finally there will be local implications for Mid-Staffordshire NHS Foundation Trust, its patients, its staff and the services it provides and probably those it stops providing. I don’t profess to be an expert on the local health system, but it is imperative that the care needs of the population (in what will inevitably be troubled & anxious times) are addressed as a matter of priority
It won’t be easy, nor necessarily pleasant, whilst these are addressed.

What I do want to discuss now is how the wider NHS, on the ground, could and should respond to the Francis Report

This week the Francis Report will be published and it will be unpleasant and damaging for the NHS, but it is absolutely right that this does all come out. The NHS needs, and patients deserve, a completely new ethos.
Some people are anxious as to whether the findings and recommendations of the report will be implemented and I can understand their concern, although in practice I am confident that they will not be “kicked into the long grass”.
In contrast to The Leveson Inquiry the recommendations are a bit more distant from politicians and thus I would be surprised if the vast majority of recommendations aren’t put in place. Reconvening the inquiry in a few years might happen and could be a useful fail-safe measure.
Regulators such as the CQC and Monitor might need to change but they or whatever replaces them will absolutely and rightly seek to ensure that Trust Boards continue to be held accountable for standards of care in their organisations. Similarly the NHS Commissioning Board and its various outposts and teams will be doing likewise. Clinical Commissioning Groups are another body with a quite legitimate interest in ensuring that the highest possible standards are maintained and that any lapses are made public and addressed. In addition there will be interest from patient groups, local media, politicians, Colleges and unions, amongst others.
Within provider organisations I expect (and indeed hope) that there will be a renewed emphasis upon core standards of care and there will be clear emphasis made to staff to of the necessity to escalate areas of concern. Indeed I would expect them to have a professional duty to do so, such as the GMC’s Good Medical Practice: Duties of a Doctor which is being rewritten and I am sure will take account of Francis. I would expect there rightly to be enhanced protection for “whistle-blowers”.

So what’s the problem and what have Trust Boards got to fear?

At first glance there is no problem and there are tremendous opportunities to make a dramatic improvement in standards. I guess my concern is the climate that will be engendered and the circumstances in which the NHS will be making these changes.
Whether we want to call it QUIPP, the Nicholson Challenge or whatever, the NHS still needs to implement the Francis Report recommendations whilst also saving huge amounts of money and essentially transforming itself into a new, leaner and more efficient organisation.
The size of the challenge and the change required is particularly focussed upon acute providers. More than two-thirds of the costs of an acute trust are staff salaries, although this understates the size of the problem. The ability of a trust to control much of its non-pay costs (e.g. fuel bills, drug prices etc) is limited. Of the costs over which a trust has some influence, around 80% is staff costs. Of the staff costs, about a third is for doctors and a third is for nurses. The final third will include other clinical staff (e.g. physios, radiographers, pharmacists etc). That final third will include “administrators” but most of them are in clinically related posts such as medical secretaries. Only a pretty small fraction is “management” and whatever one’s preconceptions (or even biases) with regard to hospital managers, their costs aren’t huge and the NHS is going to need some high class managers to see itself through the next fews years. To make the significant savings required, trusts will have to make major savings in staff costs.
Its staff are the key asset of any Trust whilst also being its biggest cost. On the positive side however, it is through its staff that any Trust will innovate and deliver high quality and efficient care.
And this is where it gets tough (and possibly dangerous). The relentless drive to cut costs will continue. To make significant savings the pay bill for all staff (including doctors, nurses & other clinicians) will need to reduce. This will have a direct impact upon staff employment and take-home pay. These staff are already busy and pressured. Indeed you only need to look at today’s Nursing Times story to see that the majority of nursing staff already have concerns about staffing levels on their wards.
These staff will quite appropriately be encouraged, or even compelled, to escalate areas of concern upwards and these concerns should, if serious, reach the Trust Board.
The vast majority of the concerns raised by staff will be absolutely genuine and motivated by the best interests of patient care. It is possibly an unpopular thing to say, but there is potential for some members of staff to raise concerns for less noble reasons. It is possible that the individual staff member is actually part of the problem or potentially sees a change to their employment circumstances. In “blowing the whistle” it is possible for some members of staff to protect themselves, their service or their job. I am sure it is a minority, but it is a risk. Separating out the interests of the patient and the members of staff could be tricky.
It says something about the culture of the NHS that even writing the paragraph above feels “risky”.

Please note that I absolutely want to encourage staff to raise concerns and Trusts must act upon these concerns and if they don’t then the staff members must be able to “whistle-blow” and must be protected. I also believe that the majority of concerns raised by star are, and will continue to be, genuine and motivated by the best interests of patients

So what will actually happen at the Trust Board?

“Essentially the key function of any Trust Board is to improve quality & safety whilst at the same time employing a few less people, to do a bit more work, for a bit less money. Apart from this, everything else is easy”

The Trust board will receive all sorts of quality scrutiny and financial pressures from above. From below there will be areas of concern being escalated by staff worried about patients (but who are also subject to employment and salary pressures).
This is a heady cocktail and obviously the welfare of patients must be the priority.
I am genuinely concerned as to how any Trust Board is going to square this circle of enhancing quality and safety, whilst also making enormous efficiency savings.
I am a member of an FT Trust Board and I am absolutely up for the challenge. It is the role of the whole Trust Board to ensure that the quality impact of any cost improvement plan is quantified, taken into account and minimised. All this is as it should be.
I am worried that some of the expectations are enormous. In general I am an regular reader of Roy Lilley’s blog. One of his blogs last week, Show Them The Door, set a potentially tone for what is ahead. Roy is quite right in that Trust Boards are accountable and must be held to account for their actions or failures to act.
I don’t expect sympathy. I have volunteered for the role of medical director, and indeed I love the job. I am well paid and expect to be held responsible and accountable for care standards. Similarly I am also well aware of needing to play my role as a clinical leader in changing the way the care is delivered in order to make savings. I’m proud of the care that is provided to the vast majority of our patients but we don’t always get it right. I happen to agree with the Secretary of State when he says that “there are little bits of Stafford dotted around the system”.
I just hope that the role expected of members of Trust Boards is doable. It is always going to be a tough job and the NHS needs the best people to take on these roles and there is a vital need for clinicians to step up to play their part. I hope we don’t reach the position of putting Trust Boards in an impossible position of being squeezed from above and below with expectations that cannot be met.
The next few weeks are going to be tough for all involved with the NHS from patients to staff. Let’s hope it emerges stronger and better.
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© 2013 Dermot O'Riordan
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