Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry April 2013 Ann Fox Director of Nursing, Quality & Safety
Findings from the first inquiry (published February 2010) • Lack of basic care across a number of wards and departments • Trust culture was not conducive to providing good care or a supportive environment for staff • Too high a priority on targets • Consultant body disassociated itself from management • Acceptance of poor standards • Management and Board thinking dominated by financial targets • Absence of effective governance • Lack or urgency to Board response to problems • Statistics and reports preferred to patient experience • Focus on systems and not outcomes • Lack of internal and external transparency
Findings from Second Inquiry • A lack of openness to criticism • A lack of consideration for patients • Defensiveness • Looking inwards and not outwards • Secrecy • Misplaced assumptions about the judgements and actions of others • An acceptance of poor standards • A failure to put the patient first in everything that is done
Key Recommendations • Governance and trust boards • Monitor and authorisation of Foundation Trusts • New fundamental and enhanced standards of quality • Duty of candour, complaints and clinical risk • Enhancements to provision of information, inspection and monitoring • Workforce issues • Commissioning for quality • Role for regulators
Expectations from Francis 2 • How lessons learned might be applied to other parts of the health economy • All healthcare organisations should consider the findings and recommendations and decide how to apply them to their own areas of work. • Each organisation should announce its progress against planned actions ( no less than once a year). • DoH should publish collective progress • House of Commons select committee on Health should consider incorporating update on actions from those organisations responsible to parliament. The whole enquiry has been focussed relentlessly on the need to protect patients from unacceptable and unsafe care.
“The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require a root and branch reorganisation – the system has had many of those – but it requires changes which can largely be implemented within the system that has now been created by the new reforms. I hope that the recommendations in this report can contribute to that end and put patients where they are entitled to be – the first and foremost consideration of the system and everyone who works in it.” • Sir Robert Francis QC (February 2013)
Headline implications for South Tyneside CCG Issues to consider: • Performance and standards • Information • Professional regulation • Values and accountability • Openness and candour • Leadership • Care and compassion • Organisational culture and staff engagement
Considerations • How far each organisation, at all levels supports a positive, patient centred, safety and quality culture across the services you commission or provide, with openness, honesty and candour inbuilt and applied within your organisational systems and processes. • Whether any organisation allows a cultural tolerance of poor practice and continuing safety issues to operate. • Whether the information which organisations produce or interpret accurately reflects what is happening “on the ground ” . • Whether the board(s) leads on improving quality across your organisation and the whole of the patient experience, or if its words speak louder than the organisation’s actions as a whole.
Considerations • How will we know that we really interrogate fully, understand and act quickly enough on quality and safety issues? • What will we do to ensure effective leadership, staff engagement and a positive organisational culture to deliver safe high quality care for patients?
Learning from Mid Staffs Inquiry • Francis is an opportunity to reassess what we (commissioners) are doing and why! • Quality and the Patient First • Getting the basics right • An open culture • Contracts that work for patients and clinicians
Initial Government Response to Mid Staffs Inquiry Statement of Common Purpose: • Renew and reaffirm NHS Constitution • Putting patients first- listening carefully and responding quickly to patients, especially the most vulnerable. • Collaborating on behalf of patients – rooting out poor care and promoting excellent care. • Outward facing – do the business of the patient, not the system or organisation.
Continued • Reduced bureaucracy- freeing up time to care and to lead. Rewarding staff for their care as well as for skills. • Single set of measures of success – focussing on what matters to patients. • Duty of candour- challenge ourselves and each other on behalf of patients. Culture of humility, openness and honesty. • Commitment to change – set out plans to make this a reality
Five Point Plan A. Preventing problems B. Detecting problems quickly C. Taking action promptly D. Ensuring robust accountability E. Ensuring staff are trained and motivated
Next Steps • Key organisations across health and social care will take the action needed to make the document a reality for patients. • Government will report on progress annually. • Develop NHS ST CCG action plan • Build on assurance from Providers
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