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Francis Report fails to address root problems: impossible targets, inadequate cash limits, fragmenting reforms

PRESS STATEMENT

Francis Report fails to address root problems: impossible targets, inadequate cash limits, fragmenting reforms

Filling three massive volumes and offering 290 recommendations the Francis Report on the scandalous failures of care at Mid Staffordshire Hospitals Foundation Trust appears to be a heavyweight offering.

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Some of its recommendations are of course welcome, not least recommendation 18 (requiring all NHS trusts and foundation trusts to review their standards, governance and performance in the light of the report); the insistence on the priority of safety and quality in patient care; and the call for enhanced leadership role for doctors and nurses.

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But despite getting some things right, the report ducks many key issues.

  • It avoids pinning any direct responsibility on any of the senior managers, commissioners or strategic health authority bureaucrats whose indifference and negligence allowed such appalling lapses from acceptable standards to go without intervention or investigation.
  • It creates a new ‘duty of candour’ and imposes legal obligations on front line staff to report failures in care, but offers them no protection, and no sanctions against those who respond with bullying and victimisation.
  • It fails to address the flawed reforms and the unrealistic financial targets that led management into such desperate actions, and therefore fails to make the connection that needs to be made between those terrible days in Mid Staffordshire and the pressures faced today by trusts up and down the country.

The shocking revelations of the sheer scale of the cash-driven cutbacks in staffing which were central to the calamitous deterioration in care are not adequately reflected in the recommendations, despite the fact that many trusts and foundation trusts – driven by the government’s insistence on the £20 billion “Nicholson challenge” are even now embarking on cutbacks as large or larger than those which were related to the tragic consequences in Mid Staffordshire.

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The report fails to engage with the broader political context of the Mid Staffordshire crisis: the changing culture of an NHS being transformed by the policy of successive governments from a public service into a competitive market, in which trusts and their directors are driven by targets and balance sheets rather than by a focus on patient care.

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The Mid Staffordshire trust, despite its serious financial problems, was being pressurised to shape up to achieve “foundation trust” status – at the expense of sharply reduced staffing levels and quality of care. But dozens more trusts are even now being driven down a similar path, towards targets to achieve foundation status, as required by the government’s controversial Health & Social Care Act, which sets the tight deadline of 2014.

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Many of them are seeking drastic savings through cuts in medical and nursing staff: the Trust Special Administrator report on South London Healthcare, endorsed only days ago by Jeremy Hunt, includes drastic cuts in clinical and nursing staff to save money. And these proposals have been finalised, and now endorsed by ministers despite a chorus of complaints by consultants, nurses, midwives and other health professionals that they will jeopardise standards. It has become routine for NHS managers and their political masters to turn a deaf ear to protests and to hope for the best when they endorse cutbacks. Mid Staffordshire managers were not exceptional on that issue.

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Robert Francis in his report declares that:

“The Board of the time collectively must bear responsibility for allowing the mismatch between the resources allocated and the needs of the services to be delivered to persist without protest or warning of the consequences. It was or should have been the directors’ primary responsibility to ensure either that they did deliver an acceptable standard of service or, if this was not possible, to say so loudly and clearly, and take whatever steps were necessary to protect their patients.” (page 211)

But this welcome, far-reaching challenge to the logic of cash limits and balancing the books, one long argued by campaigners, is not mirrored in the recommendations.

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Nor does Mr Francis explore the contradiction between this approach and the new, competitive health care market being created by the Health & Social Care Act, in which providers are required only to deliver services as contracted by commissioners. He does not discuss whether the new Clinical Commissioning Groups that will be the principal local-level bodies commissioning health care from April have the expertise or resources to monitor standards of care on the level he proposes.

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This will also be made harder as existing NHS providers, themselves already squeezed by constant cuts in tariff and referrals and requirements to deal with historic deficits, face increasing loss of market share to private sector and “social enterprises” – organisations in which scrutiny on the level proposed in the report will run against barriers of ‘commercial confidentiality’, and accountability is limited to that between a company and its shareholders.

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Given the inadequacies that have been repeatedly exposed in its performance, there are few grounds to be optimistic that the Care Quality Commission could adequately take on most of the duties of Monitor, and the prosecuting role of the HSE – and it is already clear that the CQC does not wish to do so. Francis himself pulled back from proposing to regulate senior managers – but does  propose regulation of low-paid and exploited Health Care Assistants, who are far from being the cause of the problem.

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Equally Francis appears to have quite unwarranted faith in the ability of untested local Healthwatch bodies, widely criticised for their limited brief, and lack of teeth and investigatory powers, to deliver improved scrutiny of services from April.

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But perhaps the most glaring omission, since it would have widespread public support, and carry little if any cost, is the failure to stipulate legal protection for those who have the courage to speak out and reveal problems in the quality of care. NHA party chair Dr Richard Taylor said:

“Whistle blowers were present in Stafford but they were bullied into silence. This must never again be allowed to happen. We agree that staff should have a duty of candour when they see things going wrong. NHA will support this approach, and I have in the past presented a Private Member’s Bill to the Commons proposing support for whistle blowers.”

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There is much of value in the Francis report: but if the fundamental direction of government reforms to the NHS is not addressed and halted, the brutal pressures of cash limits, business methods and the new health care market will undermine whatever measures are brought forward to improve the quality of patient care.

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Further details: nationalhealthaction@btconnect.com