From Volume 42, Issue 4, May 2015 | Pages 316-317
The professional regulators were identified in the Francis Report as having a central role in maintaining fundamental standards of care. This paper describes the key themes in the Report and the importance of regulatory powers to ensure that the serious failings in patient care highlighted by the Mid-Staffs Inquiry cannot be repeated. The central role of the GDC Standards in the profession's response to the Francis Report is stressed.
Significant failings in patient care were identified at Stafford Hospital Trust by the Healthcare Commission in 2008, including very poor treatment of older patients in particular, apparently high mortality rates for those admitted as emergencies and general inadequacies in the running of the hospital.
The Second Francis Inquiry1 which began in 2010 sought to examine the commissioning, supervisory and regulatory organizations in relation to their monitoring role at Mid-Staffs between 2005 and 2009 and why the serious problems were not identified and acted on sooner. It also had the remit to identify important lessons to be learnt for the future of patient care.
Robert Francis QC made a total of 290 recommendations, but there are five central recommendations which run through the report:
Whilst many of the recommendations within the Francis Report were not directed specifically at professional regulators, the GDC aims to use its regulatory powers to reinforce the overall approach recommended in it. These powers cover:
To be effective in exercising these powers, the GDC is working collaboratively with other regulators and the NHS. In addition, the GDC itself had lessons to learn from the Francis Report in terms of its approach to Corporate Governance, including whether we are sufficiently transparent and open about mistakes made and how we deal with patients, registrants and the public when things go wrong. We will continue to review our corporate governance and our service generally to learn the lessons of the Francis Report.
Six key themes were identified in the report:
One of the central recommendations of the Francis Report is that there should be ‘fundamental’ standards of care to which all healthcare professionals and providers of NHS care should adhere. These ‘fundamental’ standards should be set at a level below which the quality of care provided would be deemed unacceptable in any circumstances and any individual or organization responsible for providing this level of care should be subject to a criminal sanction. This recommendation was made with the intention of preventing the numerous situations identified at Mid-Staffordshire Hospital, where patients were left unwashed for days, without food or water, and without medication.
The standards of professional regulators are different from these standards for two reasons – they set the bar higher than the ‘fundamental’ level and the sanction which is introduced for breach of a standard is not a criminal one. In addition, the standard of proof for determining whether a standard has been breached is the ‘civil’ standard – ie on the balance of probabilities which is lower than the criminal one.
In its initial response to the Francis Report, the Government committed the Care Quality Commission (CQC), along with the National Institute of Clinical Excellence (NICE), to developing these ‘fundamental’ standards. It also said the following about how these standards might be enforced:
‘…in the unusual situation where staff deliberately allow fundamental standards to be breached or are obstructively dishonest, robust action should be taken. We will consider the conclusions of Don Berwick's review of safety and what further action might be taken by the Nursing and Midwifery Council, the General Medical Council and other professional regulators before deciding on the appropriateness of criminal sanctions.’
There is, therefore, a growing expectation that ‘robust action’ will be taken for breaches of the ‘fundamental’ standards, with professional regulators playing a central role. Yet, the current approach to standards taken by professional regulators has also been subject to criticism by Robert Francis subsequent to the publication of his report. He is reported to have said that the events at Mid-Staffordshire Hospital
‘… happened under a regime in which everyone was under a professional duty not to harm their patient. And where did all that get anyone?’
It is clear, therefore, that professional regulators – including the GDC – must, at the very least, consider a new approach to enforcing baseline standards of care. The GDC's own standards in this area are very clear (Standards for the Dental Team, 2013):
1.3.1 You must justify the trust that patients, the public and your colleagues place in you by always acting honestly and fairly in your dealings with them. This applies to any business or education activities in which you are involved as well as to your professional dealings.
2.2.3 You must give full and honest answers to any questions patients have about their options or treatment.
5.3.8 You should offer an apology and a practical solution where appropriate.
5.3.9 If a complaint is justified, you should offer a fair solution. This may include offering to put things right at your own expense if you have made a mistake.
8.3.1 You must promote a culture of openness in the workplace so that staff feel able to raise concerns.
8.3.2 You should embed this culture into your policies and procedures, beginning with staff training and induction.
Those standards aside, we still need to continue to act quickly and share information with other regulators and to promote open and transparent dental care provision still further. We continue to place greater emphasis on protecting patients and preventing illegal practice and on engaging with and involving patients.
The GDC actively encourages registrants to exercise candour in relation to their actions and, in 2014, we issued a joint statement on candour with the other healthcare regulators and we will be issuing further guidance on this.
The core is that ‘every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.’
We will work with other regulators, employers and commissioners of services to help develop a culture in which openness and honesty are shared and acted on.
