Francis Conversations March 2013

1. Francis ConversationsMarch 2013 Zoe Packman Director of Nursing, Midwifery and AHPs

3. Background • Report Commissioned In July 2009 by Rt Hon Andy Burnham, secretary of State for Health. • Principle purpose was to give a voice to those who had suffered at Stafford and to consider what had gone wrong there. • Francis 1 published February 2010 • Francis felt that there needed to be an investigation of the wider system to consider why the issues had not been detected earlier and to ensure that the necessary lessons were learned • June 2010 Rt Hon Andrew Lansley, Secretary of State decided it should be a public inquiry under the inquiries act 2005

4. Terms of reference • To examine the operation of the commissioning, supervisory and regulatory organisations and other agencies including the culture and systems of those organisations in relation to the monitoring role at Mid Staffordshire NHS Foundation trust January 2005 – March 2009 and to examine why problems at the Trust were not identified sooner • To build on evidence given to the first inquiry and its conclusions • Identify the lessons to be drawn from that examination as to how in the future the NHS and the bodies that regulate it can ensure that failing and potentially failing hospitals or their services are identified as soon as possible • In identifying the relevant lessons to have regard to the fact that the commissioning, supervisory and regulatory systems differ significantly from those in place previously and the need to consider the situation both then and now • To make recommendations to the Secretary of Sate for Health based on the lessons learned from the events at Mid Staffordshire and to use best endeavours to issue a report by March 2011

5. Some facts • 164 oral evidence witnesses • 87 witness statements • 39 provisional statements • 352 individual witness statements • 290 recommendations

6. Next steps • All commissioning service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of the report and decide how to apply to their own work • Each organisation should assure at the earliest practicable time its decision to the extent to which it accepts the recommendations and what it intends to do to implement those accepted and thereafter on a regular basis publish in a report information regarding its progress in relation to its planned action • The Department of Health should collate information about the decisions and actions generally and publish in a report information regarding its progress in relation to its planned action • The House of Commons Select Committee on Health should be invited to consider incorporating into its review of the performance of organisations accountable to parliament a review of the decision and actions they have taken with regards to the recommendations in the report

7. Warning signs • Loss of star rating in 2004 • Peer reviews e.g. cancer 2005, care of the critically ill child 2006 identified serious concerns about the Trusts ability to deliver a safe service and manage capacity • Health Care Commission review 2006 – trust did not meet the requirements or the reasonable expectations of the patients and the public • Auditors report identified and reported serious concerns about deficiencies in the Trusts risk management and assurance systems and made serious criticisms which called into question the accuracy and reliability of the Trusts compliance with standards • Worst 20% performing Trust in patient survey • 2007 Staff Nurse in Accident and Emergency raised serious concerns about leadership in the department and was ignored • Royal College of Surgeons post visit report described the department as dysfunctional • Financial recovery plan – staff cuts were identified in an organisation having serious problems delivering on quality and minimum standards • Foundation Trust application – focussed on financial and governance issues not quality issues • Health Care Commission had been launched into workings of the Trust but other bodies didn’t ask questions why or about the findings

8. Analysis and evidence • Board and other leaders failed to appreciate the enormity of what was happening, reacted too slowly and downplayed the significance of others tolerance of poor standards focused was on finance and targets • Culture of self promotion rather then critical analysis and openness • Consultants were not at the forefront of promoting change • No culture of listening to patients • Inadequate process for dealing with complaints, serious incidents and the results of the staff and patient surveys • Board failed to get a grip on its accountability and governance structures • Leadership focussed on financial issues and paid insufficient attention in relation to quality of service • Unacceptable delay in addressing the issues of shortage of skilled nurses • Inadequate staffing levels, poor leadership, recruitment and training, declining professionalism, tolerance of poor standards • Trust prioritised finance and foundation trust application over quality of care • Patients and relatives excluded from effective participation in the patients care

9. Analysis and evidence • Overview & Scrutiny Committee - Lost sight of its duty to scrutinise. • General Practitioners - did follow up patients concerns. • The Coroner lacked clarity and consistency with regard to disclosure of information by the Trust. • Primary Care Trusts. - there was a lack of clarity in regard to whose job it was to ensure safety and quality standards, limited clinical expertise, failure to investigate HSMR. They received no information on the substance of complaints, did not engage with clinicians and did not visit or inspect the Trust. • Local Members of Parliament (MPs) asked the right questions but were too easily reassured. • Unions were unaware of problems at the Trust, the RCN in particular. • The Strategic Health Authority did nothing to assess clinical risk, including no assessment of the impact of cost improvement plans. The inquiry criticised the length of time taken to carry out a workforce review overseen by the Director of Nursing. There was failure to undertake an adequate handover. The system was inadequate and there was evidence that the SUI function was under-resourced • Monitor – there was a failure to appropriately explore quality issues with the Trust during the application process. The process to become a Foundation Trust was seen as being an indicator of good quality but was not assessed.

10. Where are we - Nursing • 40.28/66.02 RNs recruited 66/61.49 HCAs recruited • Case for reviewed skill mix presented to EMG, mobilisation plan to be agreed 18 March 2013 Includes supernummary time for ward leaders • Safer Nursing care Tool used twice to be repeated, case for change developed currently shows 3 - 4 RNs per ward to meet patient acuity requirements • E rostering policy written • Master vendor contract started January 2013 • Nurse Specialists - baseline activities identified to be re run March 2013 • Enrolled on Nurse Productivity programme • 4 Associate Practitioners on programme at Kingston university • 2 additional Practice development nurses in post (10 in total) • Productives facilitator post created • Specialist areas establishment review to commence March 2013 • Community establishment reviews being undertaken in line with contract review • 20 midwives appointed ratio filling vacancies for 1:30, 6 midwives to be appointed for ratio 1:29, 5 midwives 1:28 2013/2014

11. Where are we - complaints • Care Quality Commission (CQC) inspection in November 2011 found moderate concerns with the system for managing and monitoring complaints. A subsequent CQC inspection in June 2012 acknowledged the work that had been done and the Trust was found to be compliant. • 49% of complaints are responded to within 25 days of receipt. • The Executive Director lead for complaints reverted to the Director of Nursing, Midwifery & AHP from the Director of Operations in September 2012. • The Trust has a dedicated team to manage complaints / concerns from patients. The team has been re-structured and strengthened including the appointment of a Complaints & PALS Manager • The Trust has a complaints policy and procedure which is NHSLA compliant. The policy was ratified in February 2012. • An internal audit of management of complaints was completed as part of the Trust’s Internal Audit Plan showed limited assurance

12. Where are we – governance structures • Trust Governance structures were reviewed in 2012 by Chairman • 2013 Interim Chairman undertaking a further governance review, including reviewing training required for Board members and the requirement for a clinical Non Executive Director • Directorate Performance & Quality Boards are developing following clinical service restructure in 2012

13. Where are we – patient and public involvement • Patient Issues Committee established • FT Membership, currently stands at 4600. Bi-monthly engagement meetings • Members of patient representative organisations in Croydon make up the membership of the Trust’s Patient Issue Committee. • A number of patient user group exist within the organisation, which support service improvements.

14. Where are we – SIs • There is a weekly Executive Review of all high grade incidents and trends of concern which enables Directors to be fully informed and involved • Establishment of a Patient Safety Committee, chaired by the Medical Director to lead improvement work based on internal and external intelligence • Serious incidents are presented at clinical governance sessions, directorate and corporate meeting, incorporated into inductions, teaching and simulated learning programmes • A For Learning & Action Group (FLAG) with membership inclusive of commissioners established to provide scrutiny to serious incident root cause analysis (RCA) and to ensure learning and actions for improvement. Action plans from RCAs are monitored at Patient Safety Committee • Patient Safety & Quality Bulletin, to share learning and best practice • Internal safety alerts are devised, agreed and circulated throughout the organisation where the seriousness and frequency of an incident indicate their necessity

15. Where are we – Staff engagement • Work has been done to actively encourage staff to report concerns. The whistleblowing policy was reviewed and title changed to the Speak up Policy to reflect the desired ethos • Presentations of the 5 Patient Promises and individual staff responsibility for raising concerns is made clear at Trust and clinical induction • Incident reporting via the Datix system is actively encouraged. Reports are investigated and there is feedback to the person reporting the incident • HR keep a log of all Whistleblowing incidents and investigate as far as possible from the information provided • There is a policy for supporting staff involved in incidents which details the resources available. For example, free professional staff counselling is available for self-referral • We have embarked on a Listening into Action (LiA) improvement programme of hearing staff concerns about their work and establishing 10 improvement programmes which will most impact staff experience and the organisation

16. What do you need to do? • While the inquiry was confined to Mid Staffs, there is evidence there are other places where unhealthy cultures, poor leadership and an acceptance of poor standards are too prevalent • Robert Francis' first recommendation is for everyone in the NHS to urgently consider and review what happens in their own organisation in light of the inquiry's findings, and identify any actions they may need to take to ensure what happened in Stafford does not happen in their organisation • Sir David Nicolson said in his letter to CEOs February 2013 said: ‘So please, read the report, reflect upon the findings, discuss and debate the recommendations with your colleagues, friends and families. Most of all, talk and listen to the patients you serve, and together we can build a momentum for improvement, and an NHS of which we can all be proud.’