15 March 2013

What Francis means for the NHSA brief overview

Overview of today’s presentation

• Brief overview of the Inquiry and its report

• Look at the main areas of recommendations

• Highlight what the NHS Confederation and NHS Employers have

and will be doing on the report

Other resources:• Web pages: NHS Confederation and NHS Employers• Prezi• Member briefing• Discussion paper on assuring high quality care and manager

regulation• Slide pack

The Francis Inquiry and its report (1)

• Full public inquiry into Mid Staffordshire Foundation NHS Trust

launched June 2010

• Chaired by Robert Francis QC

• Builds on earlier independent inquiry published Feb 2010

• Terms of reference:• Examine the commissioning, supervisory and regulatory organisations in

relation to their monitoring role between January 2005 and March 2009 • Why the Trust’s problems not identified and acted on sooner• Identify lessons for the NHS and regulatory bodies to ensure failing (and

potentially failing) hospitals or services are identified as soon as practicable • Take account of recent changes to the commissioning, supervisory and

regulatory systems and consider the situation both then and now .

The Francis Inquiry and its report (2)

• 290 recommendations• 3 volumes and an executive summary • 164 witnesses gave oral evidence• Structured around:

• warning signs that existed and could have revealed the issues

earlier • governance and culture • roles of different organisations and agencies • present and future.

The Francis Inquiry and its report (3)

• Mid Staffs was a system failure, as well as a failure of the

organisation and individuals

• A fundamental change in culture required

• Change will not result from “top down” pronouncements or

significant reorganisation of the system

• Need to secure the engagement of every single person serving

patients in change

• NHS (collectively and individually) must be held accountable

• No single recommendation should be regarded as the solution to

the many concerns identified.

Robert Francis Press Conference Statement

• We need a patient centred culture, no tolerance of non compliance with

fundamental standards, openness and transparency, candour to

patients, strong cultural leadership and caring, compassionate nursing,

and useful and accurate information about services

• The Trust Board was weak and did not:• Listen sufficiently to its patients and staff • Ensure the correction of deficiencies brought to its attention. • Tackle the tolerance of poor standards • Tackle the disengagement of senior clinical staff from managerial and

leadership responsibilities.

• What has been found to be wrong here cannot be cured by finding

scapegoats, and/ or recommending major reorganisations yet again.

Key themes: Putting patients first

Need to align culture first and foremost with the needs and care of patients:•Effective services from caring and compassionate staff and protected from avoidable harm and any deprivation of their basic rights

•A common set of core values and standards of behaviour

•Role of the Constitution

•All levels of the NHS:• Wards• Provider• System

•Role of strong, stable leadership

•Role for peer review

•Use of cultural barometer to measure cultural health of all parts of the system

Key themes: Listening to patients

Real involvement of patients and the public in all that is done:

• Real time feedback

• Effective complaints handling and learning from complaints:• Any concern treated as a complaint• Consistent approach but with a number of different methods/ entry modes• Advice and advocacy support needs development• Role for Commissioners: real-time information on complaints & outcomes• Complaints data to CQC and local scrutiny bodies• Government set up Complaints Review led by Trisha Hart & Ann Clwyd MP

• Patient and public engagement structures:• Critical of previous PPE arrangements • A consistent basic structure for Local Healthwatch• More support for local scrutiny committees• Coordination between Local Healthwatch, Health and Wellbeing Boards and

local scrutiny committees

Key themes: Openness, transparency & candour

Openness, transparency and candour throughout the system on matters of concern:•Statutory duty of candour: individual and organisational

•Full disclosure where death/ serious harm may have been caused

•Requirement to provide open and honest information to:• Public• Regulators

•Criminal offence for any registered healthcare professional or director of organisation to fail to provide honest information or obstruct that process

•Raising concerns

•Incorporate principles into NHS Constitution and contracts

Key themes: Standards

• Single comprehensive standard covering all aspects of governance

• Hierarchy of healthcare standards:• Fundamental: covered by regulation

• Understood and accepted by patients and staff • Set by NICE and/or Royal Colleges • Evidence-based compliance, potentially covering staffing levels• Zero-tolerance of non-compliance with standards

• Enhanced quality standards: managed by commissioners • Designed to drive improvements

• Discretionary developmental standards:• Formulated by providers and commissioners • Longer-term goals for providers to improve effectiveness

Key themes: Regulation• Strengthened CQC as regulator of all NHS trusts:• Monitor compliance with fundamental standards• Emphasis on inspection/ direct observations of care • New criminal offence of causing death or serious injury to a patient

through the breach of regulatory requirements• Interim measures to prevent patient harm while investigating • Take on Health & Safety Executive prosecution powers

• Monitor: economic regulator• Authorisation and oversight of FTs should pass to CQC• Support for fit & proper person licence test

• Professional Regulation:• Fitness to practice: need to improve performance/ be more proactive• Closer coordination with CQC

• Better sharing of information/ collaboration between regulators required

Key themes: Leadership and accountability• Accountability for everyone who provides care – individuals and

organisations

• Creation of a leadership college: • Provide standardised training to potential managers• Potential basis of an accreditation scheme

• Accountability for senior managers & leaders:• Common code of ethics, standards and conduct as part of their

contractual obligations• Support for a ‘fit and proper persons’ test – to include:

• examination of a director's fitness to be in post• requirement to comply with a common code of conduct

• Disqualification of anyone found to be in serious non-compliance with

the code from holding another senior post

• Regulation of managers kept under review

Key themes: Nursing & medical practice

• Nursing: • Enhanced recruitment, training, education and support, including shared

values and common culture• Revalidation and responsible officer for nursing• Strengthen nurse leadership & ward managers• Key nurses/ regular ward rounds

• Older People’s Nurse

• Healthcare assistants:• Registration with NMC• Code of conduct• Training standards• Government established Review (chaired by Camilla Cavendish to report

end of May

• Medical training and education

Key themes: Commissioners

• Role in defining, monitoring and improving quality• Duty to require and monitor delivery of fundamental standards• Make the final decision on what services are provided at a local level• Able to lay down a fundamental safety and quality specification• Drive quality improvement through:

• enhanced standards set out in contracts• developmental standards

• Monitor the performance of every commissioning contract:• Able to intervene:

• In complaints handling if feel an individual case not dealt with properly• If unsafe or substandard services are being provided

• NHS Commissioning Board and local commissioners should develop a code of practice for managing organisational transitions

• Accountability of commissioners to the public

• GPs monitoring role on behalf of their patients.

Key themes: Information

Information:• Clarity about performance and outcomes will help change the NHS culture

• Continuous improvement of measuring and understanding performance of individuals, teams and organisations

• Common information practices, shared data and electronic records

• Information available to patients to support choice

• Comparable quality accounts: external assurance

• Board level member responsible for information in every provider organisation

• Using patient feedback

What we will be doing as our response to Francis

• Two member seminars to discuss the report’s recommendations

• NHSE programme of 6 meetings with HR directors in February

• Consulting members on how we assure quality in the system

• Implementing phase two of the Commission on Dignity

• Working to reduce bureaucracy in order to create more time to care

• Working with the Royal Colleges to establish actions that managers and clinicians can work together on

• Looking at a mentoring scheme for members on quality

• Exploring the concept of restorative redress with nine Trusts