The report made a total of 290 wide-reaching recommendations. In essence, Robert Francis QC concluded that almost all the organisations within the NHS failed to some degree to appreciate the growing evidence about care failings at Stafford hospital or do enough about it. Francis stated that the Trust board had failed to tackle a negative culture that arose from a focus on meeting targets and gaining Foundation Trust status at the expense of care. Furthermore the broader NHS organisation failed to spot the problems at Mid Staffs and return care to acceptable standards.
The publication of the report attracted widespread publicity and media attention, with many healthcare regulators and arm's length bodies providing detailed responses and pledging to improve the outcomes of regulation. It also led to a number of other enquiries, including the Keogh Review into hospital mortality rates, the Berwick Review into patient safety, the Clwyd Report about the handling of patient complaints and the Cavendish Review into Healthcare Assistants and Support Workers in the NHS and social care settings. This is in addition to the radical reforms implemented on 1 April 2013 as part of the Health and Social Care Act 2012.
So what effect has the report had at a "grass roots" level? Jeremy Hunt told a healthcare conference in London that the NHS had changed for the better.
He spoke about the ‘Francis Effect’, including failing hospitals being put on the road to recovery, more nurses on the wards, more doctors, and feedback direct from patients changing the way hospitals work. He described seeing first-hand how the Report is being used as a "catalyst to improve care" and stated that “we have seen a real shift in priorities - new inspections, more nurses and a stronger voice for patients, with compassionate care starting to replace tick-box targets as the major focus on boards and wards.”
Mr Hunt identified a number of other changes which had already taken place, including an extra 2,400 hospital nurses hired since the Francis Report, with over 3,300 more nurses working on NHS hospital wards and 6,000 more clinical staff overall since May 2010, nearly 40 per cent of hospitals now have the names of a senior responsible doctor above patients’ beds, and 140 Department of Health staff spending at least a week working on the frontline of the NHS, totalling around 1,000 days on the frontline.
However, according to a survey by The King's Fund, 64 of England's 145 hospital trusts – 44% - predict they will be in debt by the end of next month. 22% of NHS finance directors expected to be in deficit at the end of next month, along with 13% of clinical commissioning groups, which buy services on behalf of GPs. According to figures from Monitor and the NHS Trust Development Authority, the trust regulators, the combined deficit could reach £330million.
There have also been significant changes by the bodies regulating NHS services. The Care Quality Commission ("CQC"), on the recommendation of Francis, has appointed a new Chief Inspector of Hospitals, Sir Mike Richards, and has already implemented a new inspection process involving a wider team of healthcare experts. This will include publishing hospital ratings aimed at enabling patients to compare hospitals.
The CQC will also be implementing fundamental standards, a core part of the report's recommendations, as changes to its registration requirements. The fundamental standards, currently under consultation, include that:
- the care and treatment of patients must reflect their needs and preferences;
- patients must be treated with dignity and respect; and
- the nutritional needs of patients must be met.
One of the key failings mentioned by the report was the lack of collaboration between Monitor and the CQC while Mid Staffordshire applied to become a Foundation Trust. Monitor and the CQC are now due to launch a joint licensing and inspection system where the CQC's monitoring of care and Monitor's inspection of governance will go hand in hand.
There has been a significant increase in action taken by Monitor to intervene in struggling foundation trusts, and currently eight foundation trusts are under special measures, whereby Monitor can force them to make changes to their governance arrangements. Monitor is also taking regulatory action against a further eighteen foundation trusts and is investigating a further eight foundation trusts. Monitor has announced that this, as well as completed actions, is double the number of interventions it made prior to the report as there was now “a declined appetite for risk” among “Parliament, the government and the public”.
Under the Care Bill, due to reach the report stage in the House of Commons soon, Monitor will have the power to place Foundation Trusts into special administration (as used for Mid Staffs itself and South London Healthcare NHS Trust) for failures to meet clinical standards as well as financial difficulties, including at the direction of the CQC.
One of the few Francis recommendations not supported by the Government is that healthcare assistants should be registered. However, Health Education England and the NMC are piloting a scheme where nursing students will be required to first complete a period of time as a healthcare assistant. Furthermore, the Government has committed to requiring healthcare assistants to hold a Certificate of Fundamental Care, currently being developed by Health Education England.
The Government will also create two new healthcare offences, including the concept of wilful neglect. Under the Care Bill, care providers could also be convicted for providing false or misleading information (most likely to regulators) as part of the duty of candour recommended by the report. Whilst it was originally suggested that the duty of candour may be placed on practitioners as well, it is now expected that an individual duty of candour will be realised through professional regulation.
Despite these changes, one of the key recommendations of the Francis Report is that a change in culture within the NHS was needed, so that care was the main focus rather than targets. The current financial problems in the NHS, as well as headlines focussing on issues such as A&E waiting times, may not sit comfortably with the report recommendations to prioritise care rather than facts and figures and balancing the books. The relationship between the "Francis Effect", closer scrutiny by regulators such as Monitor who are more ready and willing to intervene, and a worsening crisis in NHS funding seems set to be a stormy one.