What we have learned from the Francis Report

1. What we have learned from the Francis Report Claire Barkley Medical Director SSSFT

2. Overview • Background- Francis I and II • Comments on the report • What does it mean for us? • Focus on culture and leadership

3. Sir Robert Francis QC

4. Francis I The First Inquiry published February 2010 • Lack of basic care across a number of wards and departments • Culture neither conducive to good care nor to staff support • Low morale, lack of openness and acceptance of poor standards • Management thinking dominated by financial pressures (and achieving FT status)

5. Francis I (continued) • Absence of clinical governance and lack of urgency in board’s approach to problems • Focus on systems rather than outcomes; statistics and reports rather than patient experience data • Lack of internal and external transparency regarding existing problems

6. Francis II The second Inquiry published 6th February 2013 • Signals a need for significant culture change in NHS • Examines roles of agencies involved with events at Mid Staffs during 2005-2009 • Conclusions are drawn from 300 witness statements and further consideration of first report • 290 recommendations

7. Recommended • New statutory duties (candour) • New criminal offences (deliberately misleading regulators) • “Every single person and organisation within the NHS…needs to reflect from today what needs to be done differently in the future”

8. Responsibility to consider what is exposed by my two inquiries and to consider how to apply the lessons themselves, individually and collectively • Organisations to report publically on regular basis on whether have accepted my recommendations and what they are doing to implement them • House of commons select committee to review (progress) regularly

9. Hospitals need more compassion, not cash • Horror stories -1,200 deaths • Inhumanity on a horrifying scale • Devastating report • Managers obsessed with Labour’s targets • Patients ruthlessly neglected – left lying for days in their own excrement or driven by desperate thirst to drink rank water from flower vases • Many were sent home with life-threatening illnesses • Culture of bullying and neglect spread from top to bottom • Anguished complaints of relatives were simply ignored Daily Mail Comment 7 February

10. 5 main recommendations: • Clearly understood fundamental standards and measures of compliance • Openness, transparency and candour throughout the system • Improved support for compassionate and committed nursing • Strong and patient centred healthcare leadership • Accurate, useful and relevant information

12. Commentators What was said in Health Service Journal (HSJ)?

13. Those in favour.. • Genie out of bottle in terms of principles and values being more important in how we manage NHS • You could summarise the whole document in one sentence-we have lost the focus on caring • It is a reference point for what is going wrong and should not happen again • Taps into what people are thinking • Has identified a problem which must be addressed

14. Criticisms… • Good stuff tends to be very woolly and motherhood and apple pie • If you are trying to change the culture, putting the fear of God into everyone is not necessarily the way • It is like seeing the right label on the door and when you open the door there is nothing there • He relies too much on the NHS Constitution. The vast majority don’t know it exists • I don’t see Francis as an inflection point

15. Government response 5 (different) themes: • Prevention of problems • Detection of problems at early stage • Taking action promptly to remedy problems • Robust accountability • Staff training

16. What have commentators said? • Endorses main message that listening to and understanding patients must come first Focus on 5 areas: • Vulnerable elderly care standards • Development by CQC with patients, staff and other stakeholders • NHS Constitution • Clarification of regulatory arrangements • Enhance use of real time data on quality Nuffield trust (19th March)

17. HSJ Expert Panel • HSJ gathered panel of 15 experts 13 March 2013 • Half said poor care likely to remain at same level and half said likely to get worse • Pointed to role of organisational changes and tensions in causing worsening of situation • Impact of removal of 4% of tariff year on year • Nursing burnout second only to recession-hit Greece

18. HSJ (cont.) • Incentivised the wrong things- nurses encouraged to move away from bedside • Political reform, reluctant workforce, top-down fixing, enforcement, perfect storm for more disasters in health care system • What happens to staff in health care system? • Start out motivated and optimistic • Something our system does to staff… • Raising concerns, challenging poor practice

19. Eyes and ears of the service • More people working on financial probity that clinical quality? • Different culture in US-senior staff looking at quality data weekly • Costs to individual of whistle-blowing • Tradition in NHS of saying what people want to hear

20. Glitterisation of NHS-celebrating brilliant stuff and in denial about badstuff • Suggestion of HSJ whistleblower of the year award- Golden Whistle (Phil Hammond)

21. Reasons we do not address poor care • Never a secret • Worry about reputational damage prevents us responding to concerns in open manner

22. Nuffield Trust • Focus on development of standards of care for vulnerable elderly • Lead role to CQC • Promotion of NHS Constitution in staff recruitment, induction and appraisal • Clarification of regulatory arrangements • Enhanced real time data collection to measure quality of care

23. What does all this mean?

24. Francis Frenzy • Risk of fragmenting the report and designing action plans without seeing the whole context • Hitting targets and missing the point • We feel uncomfortable…easier to act than reflect on what happened • Were those people different from us? • How could they have overseen patient care which so obviously fell short and amounted in some cases to cruelty and neglect?

25. Why did they do it? • Were staff conforming to an unspoken code of conduct or rule? • Had process taken over? • Not seeing the impact of their actions? • Or ignoring it? • Depersonalising care • Dehumanising patients

26. Perhaps • We do what is expected and if others appear comfortable it is hard to resist • If we do not see the direct impact we can be less sensitive (managers?) • Good people do bad things.. • Surely there are other places where this occurs…

28. Given the right setting conditions, people behave in ways they would otherwise consider harmful • Social pressure and conformity • We know morale is low (doctors worldwide according to Edwards and Kornacki 2002) • Need for a new compact?

29. Isabel Menzies Lyth

30. Menzies Lyth, Isabel (1959) 'The Functions of Social Systems as a Defence Against Anxiety: A Report on a Study of the Nursing Service of a General Hospital', Human Relations 13: 95-121; reprinted in Containing Anxiety in Institutions: Selected Essays, vol. 1. Free Association Books, 1988, pp. 43-88

31. Isabel Menzies Lyth Need to take a wide view of an institution in assessing its effectiveness in carrying out its primary task. Would include: • the whole way the institution functions • its management structure, including its division into sub-systems and how these relate to each other • the nature of authority and how it operates, • how it manages anxiety • social defence systems built into the institution • its culture and traditions

32. What is meant by Culture? • A pattern of shared basic assumptions- invented, discovered or developed by a given group as it learns to cope with its problems of external adaptation and internal integration-that has worked well enough to be considered valid and therefore to be taught to new members as the correct way to perceive, think and feel in relation to those problems (Schein, 1985)

33. Emphasis on Culture • “A fundamental culture change is needed” • Francis’ approach to culture criticised as being aspirational and too broad brush • However research into culture, its nature and how it is changed shows it can be shaped and this can produce benefits, but this is a nuanced area and more complex than portrayed by Francis

34. Davies and Mannion argue that a common culture as recommended by Francis may be neither possible nor even desirable (BMJ 23/03/13) • Organisational culture • Values • Beliefs • Assumptions • Ways of thinking that are translated into common and repeated patterns of behaviour

35. Maintained and reinforced by the rituals, ceremonies and rewards of everyday organisational life • “The way we do things round here” • Plus the shared ways of thinking which underpin these norms • Culture in large organisations rarely uniform

36. The cultural paradigm • Stories • Symbols • Routines and rituals • Controls • Organisational structures • Power Johnson and Scholes

37. NHS Staff United only by 2 main issues: • The need for care to be based on individual need rather than funding • Dislike of constant interference into healthcare provision by successive UK Governments Morgan and Ogbonna

38. Culture Simply urging people to think differently is unlikely to over-ride the complex personal and social forces that shape organisational behaviour

39. Culture eats strategy for breakfast

40. Health care cultures • Multiple, competing subcultures, some focussed on professional groups • Linked to teams, wards, services, hospitals • Differences in power • Struggles for legitimacy • Striving for cultural uniformity may be over optimistic

41. Ambulance crews, support structures, emotional burden of caring Prof John Glasby • Attempts at cultural manipulation and performance management might have unintended dysfunctional consequences • Perhaps better to concentrate on the individual’s responsibility to make appropriate choices and act professionally • There is not a single set of prescriptions to apply to each group as different pressures apply

42. Culture formation • Group • History of shared experience • Shared learning • Stability of membership • Human need for stability, consistency and meaning • Culture The King’s Fund

43. 3 problems relating to culture • Socialisation- teaching newcomers • Behaviour- cultural predispositions and situational contingencies • Subculture • Normal- relate to different experiences and assumptions • Often in conflict e.g. managerial and professional • Common assumptions in a crisis

44. Culture follows the leader • Cannot consider culture apart from leadership - need to look at both • Leaders need to be conscious of culture • New groups and organisations create new cultures • Once cultures exist the leaders influence the leadership criteria- who will and will not lead • To influence culture you need to be a learning leader

45. Trusts most capable of buffering shocks had: • Stable leadership • Participative cultures with strong engagement • Emphasis on organisational learning McKee, West et al 2010

46. Research shows leaders’ actions speak louder than formal communication The argument for changing my behaviour- • Leadership 65% • Communications 10% • Systems and processes 25% • Grapevine ? Schein

47. Solutions? • Assess national initiatives before implementation • Support whistleblowers and enable support for those who raise concerns • Qualitative and quantitative data • Advocates, leaders • Openness • Develop our own leadership skills

48. RCPsych • Passing on concerns • Medical leadership • Independent regulator

49. Leadership is key

50. Francis Report : Leadership 214 Shared training A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership and management as a profession; administer an accreditation scheme to enhance eligibility for consideration for such roles; promote and research best leadership practice in healthcare