Following an extensive inquiry into failings at Mid-Staffordshire NHS Foundation Trust, Robert Francis QC published his final report on 6th February 2013.

The Francis Report tells the story of appalling suffering of many patients within a culture of secrecy and defensiveness.

Although the public inquiry was focused on one hospital, it highlighted a system failure within healthcare. As a consequence the 1,782 page report has 290 recommendations which had major implications for all levels of healthcare services in England.

At the end of March 2013, the Department of Health (DH) published their initial response to the Francis Inquiry report – Patients First and Foremost. The document set out a collective commitment and plan of action for the whole health and care system and everyone who works in it. Actions set out in the document include:

• new Ofsted-style ratings for hospitals and care homes overseen by an Independent Chief Inspector of Hospitals and Chief Inspector of Social Care;
• a statutory duty of candour for organisations which provide care and are registered with the Care Quality Commission;
• a review by the NHS Confederation on how to reduce the bureaucratic burden on frontline staff and NHS providers by a third;
• a pilot programme which will see nurses working for up to a year as a healthcare assistant as a prerequisite for receiving funding for their degree; and
• nurses’ skills being revalidated, as doctors’ are now, and healthcare support workers and adult social care workers having a code of conduct and minimum training standards.

Following the initial DH response, PSNC undertook an initial review of the Francis Inquiry report and agreed to work with the other pharmacy bodies over the following months to consider the actions community pharmacy needed to take in response to the report.

A PSNC Briefing on the Francis Report summarises the key points from the Inquiry and the DH response. The briefing also highlights some of the actions and issues raised in the DH response that could be applied to community pharmacy.

Berwick Review into patient safety

In early 2013, Professor Don Berwick, a renowned international expert in patient safety, was asked by the Prime Minister to carry out a review following publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.

Following five months of work, his independent report – A promise to learn – a commitment to act: improving the safety of patients in England – was published in early August 2013, recommending that NHS staff should be supported to learn from mistakes and patients and carers must be put above all else in an attempt to make the NHS a world leader in patient safety.

The report examines the lessons for NHS patient safety from healthcare and other industrial systems throughout the world. His four key findings were that:

1. The quality of patient care, especially patient safety, should be paramount;

2. Patients and carers must be empowered, engaged and heard;

3. Staff should be supported to develop themselves and improve what they do; and

4. There should be complete transparency of data to improve care.

Recommendations in the report included:

• The NHS needs to adopt a culture of learning – this cannot come from regulation, but from ‘countless, consistent and repeated’ messages to staff so that goals and incentives are clear and in patients’ best interests;
• Staffing levels must be adequate, based on evidence – the report echoed the Keogh review in saying that staffing levels cannot be dictated from the centre, but that boards and local leaders should take responsibility for ensuring that clinical areas are adequately staffed;
• Connecting with patients and the frontline – leaders need first-hand knowledge of the reality of the system and the patient voice must be heard and heeded at all times;
• Complaints systems need to be continuously reviewed and improved;
• Transparency must be complete, timely and unequivocal;
• There is no single measure for safety – the NHS should continue to use mortality rate indicators to detect potentially severe problems. But these indicators remain a “smoke alarm” and should not be used to generate league tables;
• Supervisory and regulatory systems should be clear – an in-depth, independent review of the structures and the regulatory system was to be completed, once changes made have been operational for three years; and
• New criminal offences should be created – around recklessness or wilful neglect or mistreatment by organisations or individuals and for healthcare organisations which withhold or obstruct relevant information. But the report emphasised that the use of criminal sanctions should be extremely rare and unintended errors must not be criminalised.

The report did not recommend that a statutory duty of candour for healthcare workers be introduced – instead it found that this duty was adequately addressed in professional codes of conduct and guidance. Above all else, the report argued that cultural change was the most important factor in continuously reducing harm. In particular the report distinguished clearly between mistakes and negligence and the need for a transparent culture where mistakes are reported and learnt from.

The solutions in the report are grouped under the following themes:

• Recognise the need for systemic change;
• Abandon blame as a tool – distinguish between errors and misconduct;
• Reassert the primacy of patients and carers;
• Use targets with caution – they have a role en-route to progress, but they should never become the end in itself;
• Recognise that transparency is essential;
• Ensure that responsibility for safety is clear and simple, with cooperation among the agencies involved;
• Give NHS staff career-long help to learn, master and apply modern methods of quality control; and
• Focus on pride and joy, not fear.