The Francis Report into the deaths at Mid-Staffordshire NHS Trust highlighted the problems facing the NHS when patients, families, clinicians and nurses are not heard, and where the management, leadership and ensuing culture are focused on the system's business, not patient care. This paper, the first in a series based on the implications of the Francis Report, provides the background and context for the subsequent ‘perspective’ articles from a range of relevant stakeholders and care-providers. The overriding message is that in all areas of healthcare, dentistry included, the quality of patient care, especially patient safety, must be placed above all other aims.
Clinical Relevance: The overriding importance of patient-centredness and quality of care, above all other aims, is the key message of clinical relevance from the Francis Report.
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What is the Francis Report?
Numerous media reports in recent years have highlighted significant lapses in quality of care across the full spectrum of medical and social welfare settings. Such reports result in a significant loss of trust by members of the public in services that exist to support and look after them. In many cases, investigations and public enquiries have followed reports of failings in these settings, but little seemed to change.
In 2010, however, Robert Francis QC published his report into the significant problems identified by patients and their relatives at the Mid-Staffordshire NHS Trust.1 This report showed starkly the level to which care standards could slip for patients in a modern-day NHS hospital. The transcripts of relatives' descriptions of the appalling lack of care and respect to which their family members were exposed make very distressing reading. This is an example from December 2007:
‘The patient was admitted to Ward 11 at Stafford Hospital, where her family were shocked to find that after four days they were not given any information regarding her treatment. Only after several requests from her daughter was a meeting arranged. One night the patient urinated in her bed three times as she was unable to reach the buzzer, when she tried to move from her bed as she received no response from the buzzer she suffered a sprained ankle.
The patient was often left for long periods shivering on a commode despite suffering from pneumonia and was not given fluids despite her dehydration. Nurses had left mouth swabs on the table but did not use them and her family were unaware of their purpose.
On one occasion the patient was diagnosed with liver cirrhosis due to a drinking problem, although her daughter assured doctors that her mother did not have such a problem. However, she was later diagnosed with anaemia. When she was due for a transfusion the wrong blood was brought due to a mix-up with her date of birth, even though her daughter had already informed nurses of the date error.
The patient suffered oral thrush and bedsores for days before they were treated. Her family found her left in a bed with pads underneath her and a sanitary pad between her legs, she had been told to urinate in her own bed throughout the day. When her family complained the matron responded with shock and disgust but little improved.
The patient was due to be transferred to a hospice, however this was delayed due to her suffering from diarrhoea. It was not until days later that it transpired she was still being given constipation medication and was suffering unnecessarily for a number of days.
Her daughter found PALS to be supportive but they were unable to change the conditions on the wards.'
The issues raised in this report represented a watershed and the failings were so extreme that the Secretary of State established a second inquiry, also chaired by Robert Francis, to examine the commissioning, supervisory and regulatory organizations in relation to their monitoring role at Mid-Staffordshire NHS Foundation Trust. There were questions to be answered about why the serious problems cited in the 2010 report had not been identified and acted on sooner and a need to identify what lessons could be learnt to improve patient care into the future. This second report2 was published on 6 February 2013 and listed numerous warning signs which could and should have alerted the system to the problems developing, but which were missed. The report identified a number of the possible causes, within which are critical messages for all involved in delivery of healthcare and its regulation. Following detailed analysis, the report contained 290 recommendations centred on the five themes of fundamental standards:
Openness;
Transparency and candour;
Nursing standards;
Patient-centred leadership; and
Information about performance against service standards.
The content of the Francis Reports was based on problems that had arisen in a secondary care medical setting, but the implications and recommendations apply across the entire spectrum of healthcare, including dentistry. Indeed, oral hygiene figured as a specific item in the 2010 Francis Report1 citing, among others, the following two transcripts, one from a patient's daughter and the other from a man's wife:
‘They left my father with a crusted-up mouth, a furred-up tongue; nobody had even gone to wash his mouth or clean his mouth out with a swab or anything. You can get lemon swabs, you can swab them out and keep the mouth fresh. But nobody had done that.’
‘His mouth had been swollen, his tongue was swollen, he was covered in blisters. They gave him nothing at all for his mouth. What they suggested was he cleaned his teeth after each meal. He wasn't eating meals. They never gave him anything at all for that.’
In order to publicize more widely the relevance and importance of the Francis Report within the dental community, a meeting entitled ‘The Francis Report and the Dental Team – What it Means For You’ was staged jointly by the University of Glasgow Dental School and Royal College of Physicians and Surgeons of Glasgow, and co-hosted with the Royal College of Surgeons of Edinburgh on 4 September 2014. In order to promulgate further the content of that meeting, a number of the presenters have provided summary papers based on their lectures. This first paper gives an overview and context for the rest of the articles which provide the perspective of a range of stakeholders.
Why do healthcare failures occur?
As described above, the second Francis Report2 was established to examine why the failings at the Mid-Staffordshire NHS Foundation Trust had not been identified and corrected sooner. The Report cites a number of possible causes, which are summarized in Table 1. It is immediately clear that these statements have general applicability across healthcare, including dentistry, and that every one of them reflects a failure to deliver patient-centred care.
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 reorganization.
Table adapted from Francis R (chair). Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013.2
What can be done to address the problems?
After receiving the 2013 Francis Report,2 the UK Government commissioned Professor Don Berwick of the Institute for Healthcare Improvement in Boston, USA, to ‘Study the various available accounts of Mid-Staffordshire, as well as the recommendations of Robert Francis and others, to distil for Government and the NHS the lessons learned, and to specify the changes that are needed’. The result was a report produced by Don Berwick and his advisory group entitled A Promise to Learn – a Commitment to Act. Improving the Safety of Patients in England.3 In this report, Berwick cited four key principles at the outset (Table 2). He then listed what he believed to be the most significant of the underlying problems, as follows:
Place the quality of patient care, especially patient safety, above all other aims.
Engage, empower, and hear patients and carers at all times.
Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.
Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.
Patient safety problems exist throughout the NHS: the Mid-Staffordshire tragedy, whilst a dreadful lapse in care, was not unique within the NHS. As for all healthcare systems, ‘the whole NHS should strengthen patient safety now and into the future’.
NHS staff are not to blame: with a very few exceptions, ‘the vast majority of staff wish to do a good job, to reduce suffering and to be proud of their work. However, good people can fail to meet patients' needs when their working conditions do not provide them with the conditions for success’.
Incorrect priorities do damage: there is risk of a loss of focus by at least some leaders on both excellent patient care and continual improvement as primary aims of the NHS. ‘In some organisations, in the place of the prime directive, ‘the needs of the patient come first’, goals of (a) hitting targets and (b) reducing costs have taken centre stage’. He identifies that ‘Under such conditions organisations can hit the target, but miss the point’.
Warning signals abounded and were not heeded: extensive information was available on the poor quality of care at Mid-Staffordshire, both in terms of complaints and quantitative metrics, but ‘Loud and urgent signals were muffled and explained away’. This included, significantly, ignoring complaints of patients and carers.
Responsibility is diffused and therefore not clearly owned: the division of responsibility for quality and safety among many agencies, with unclear or at times non-existent lines of co-ordination, communication, pattern-recognition and follow-up for action is a major problem. ‘When so many are in charge, no one is’.
Improvement requires a system of support: ability to measure and continually improve the quality of patient care needs to be taught and learned, with the necessary investment in human development. ‘The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end’.
Fear is toxic to both safety and improvement: fear was generated in the Mid-Staffordshire story through ‘a vicious cycle of overriding goals, misallocation of resources, distracted attention, consequent failures and hazards, reproach for goals not met, more misallocation and growing opacity as dark rooms with no data came to look safer than ones with light. ‘”Better not to know” became the order of the day’.
Based upon these key principles and his analysis of the issues raised by the Francis Report, Berwick further defined a number of steps which he believed the NHS needed to take.3 These are listed in Table 3. They relate to the principles of patient-centred healthcare, the key importance of continuing education and personal development, and the centrality of transparency with colleagues, patients and relatives alike. These are core professional values to which we all subscribe, but the dangers of their erosion in the prevailing environment are all too real. The emergence of the business culture in health and social care, financial imperatives, lapses in communication between clinicians and managers and relentless pressure to achieve official targets can all conspire to divert us from the essential core priority of patient-centredness in all our activities. The relevance of these generic concepts to the dental profession are self-evident and our professional regulator, the General Dental Council, has already produced an action plan for responding to the Francis Report (http://www.gdc-uk.org/Aboutus/Thecouncil/Meetings%202013/11%20-%20GDC's%20Francis%20report%20action%20plan.pdf.) A paper produced by the GDC forms part of this series of articles.
Recognize with clarity and courage the need for wide systemic change.
Abandon blame as a tool and trust the goodwill and good intentions of the staff.
Reassert the primacy of working with patients and carers to achieve healthcare goals.
Use quantitative targets with caution. Such goals do have an important role en route to progress, but should never displace the primary goal of better care.
Recognize that transparency is essential and expect and insist on it.
Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.
Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.
Make sure pride and joy in work, not fear, infuse the NHS.
What progress is being made?
In February 2014, one year after the publication of the 2013 Francis Report, the Nuffield Trust undertook a study of a selection of acute trusts in England, to judge their responses. The subsequent document, entitled ‘The Francis Report One Year On’4 identified several key points, including the following:
Whilst there had been widespread welcome by staff of the recommendations to enhance openness, transparency and candour, leaders recognized that genuine culture change takes time and that many staff may still not feel comfortable in raising concerns. The recent publication of a book entitled Little Stories of Life and Death by an NHS whistle-blower demonstrates vividly the stresses and pressures that such professional actions can invoke.5 In a recent development, Robert Francis has completed a review of whistle-blowing in the NHS entitled Freedom to Speak Up, published on 11 February 2015 (http://freedomtospeakup.org.uk/the-report/), which lays down 20 principles and actions, all of which have been accepted by the UK Government.
Many senior leaders said that the Francis Report had prompted them to reflect more deeply on quality of care being delivered. It had also added legitimacy to their efforts to apportion greater weight to quality of care, alongside financial and performance targets.
Although the Francis Report reinforced the efforts of senior leaders to prioritize quality of care as equal to, or more important than, financial performance, there is still a profound tension between the two goals.
The trusts reported greater pressure from external bodies seeking quality assurance following the Francis Report. For some, the collection and validation of data required by these bodies was proving onerous.
Some senior staff stated that the culture of the external performance management and regulation system felt punitive on occasions and questioned the degree to which national bodies were able to co-ordinate their monitoring and performance management of local trusts.
Trusts reported that they had been taking action to improve the quality of hospital care prior to 2013, but that publication of the Francis Report had added impetus to this.
Many trusts had instituted their own initiatives to gather wide-ranging data about different aspects of the quality of care, particularly at ward level, often in real time and sometimes combining clinical and patient-reported data.
Conclusion
The Francis Report has exerted a major impact on UK healthcare, particularly within the acute setting. However, there is still a very long way to go before the goals set out by Francis and Berwick are achieved. This is recognized by the UK Government and is reflected in the title of its response to the Francis Report: Hard Truths. The Journey to Putting Patients First.6 This journey includes those of us in all branches of the dental profession and it is hoped that this series of papers will help to illustrate how best we should be directing our energies to overcome the challenges. Don Berwick opened the Executive Summary to his report3 by stating: ‘At its core, the NHS remains a world-leading example of commitment to health and health care as a human right – the endeavour of a whole society to ensure that all people in their time of need are supported, cared for, and healed.’ We all need to engage fully to ensure that this endeavour gets back on track and our treasured healthcare system survives in a form that is fit for purpose and fully patient-centred. This series of papers aims to focus our thoughts and energies to that end.
