The House of Commons Health Committee reports on Francis John Tingle
A
number of reports into patient safety have followed in the wake of the publication of the Francis report into the Mid-Staffordshire NHS Trust (Francis, 2013). The House of Commons Health Committee Report 2013, After Francis, is the latest. In this report, the Health Committee, which is made up of MPs, gives its view on Francis’s principal recommendations. It begins with an introduction to the report and its significance. In the Committee’s view, Francis has: ‘indicated key components of a prevailing culture at Mid Staffs which he characterises as “doing the system’s business”: by definition, this was a culture which tended to prioritise the smooth operation of the healthcare system above the safe and effective care of patients’ The report distils Francis’s 290 recommendations for change in the health and care system: ‘in truth, all can be summed up in one single recommendation—that the culture of the NHS must change in order for the safety and quality of the service, and the public’s confidence in it, to improve’.
An open and transparent NHS According to After Francis, healthcare professionals have an unambiguous professional duty to raise any concerns they may have about the safety and quality of care being delivered to patients with the relevant authorities. Managers do not operate within the same framework of regulated professional obligations, but they should also be expected to raise similar concerns: ‘Trusts and other care providers have a fundamental duty to establish an environment where concerns about patient safety and care quality raised by clinicians or managers are addressed openly and directly’.
Duty of candour John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
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The Committee agrees with Francis that the key requirement is for a ‘culture change’ within the NHS to value openness and transparency in all care delivery—not just when things go wrong. The Committee believes that the requirement for openness and transparency is too narrowly drawn in
the NHS Standard Contract. The requirement for candour about mistakes should, it argues, be seen as part of a much wider commitment to an open and accountable service. Challenge and debate about outcomes should occur at all levels of quality achievement and in all contexts of care, not just at the bottom. The Committee believes that if highquality service providers were to set the pace for openness and transparency by making properly anonymised information available on a much improved basis, they would increase the pressure on lower-quality providers to demonstrate that they were matching their standards to the very best. Verbal commitments to high-quality standards are hollow if no effective steps are taken to monitor performance. The Committee also believes that the new formulation in the NHS Constitution, explaining the duty of candour, substantially understates the importance of a more open culture in the NHS. Commissioners and providers should be under a duty of openness about the full range of outcomes achieved, not just about examples of patient harm. Francis argued for a statutory duty of candour owed by providers to patients. The review of patient safety in England, led by Professor Don Berwick, also supports a statutory duty of candour on this model, but it has reservations about its scope, since a requirement for automatic reporting of ‘every error or near miss’ could lead to more bureaucracy and detract from patient care. Francis also argued for a statutory duty on healthcare workers to report beliefs or suspicions about serious incidents to employers. The Committee is not persuaded that a statutory duty defined in secondary legislation, operating in addition to existing contractual duties and professional obligations, will necessarily be effective in achieving cultural change on the scale the NHS needs. It is concerned too that insufficient attention may have been given to how these proposed new arrangements will interact with existing processes.
Fundamental standards of healthcare and patient safety On fundamental standards of healthcare and patient safety, the Committee agrees with Francis that clear, unambiguous standards should be established in such a way that patients, relatives, clinical and auxiliary staff and managers can immediately recognise unacceptable care and take appropriate action. Any breach, the report states, should be treated seriously and investigated thoroughly, but regulatory consequences should be proportionate and focus on analysis and remedy of the circumstances that led to the breach. Where breaches of these standards risk harm to patients, or lead to death or serious injury, the breach should be treated as a criminal matter. The Committee notes the Berwick Review’s recommendation
© 2013 MA Healthcare Ltd
John Tingle discusses the House of Commons Health Committee report, After Francis
British Journal of Nursing, 2013, Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety that an offence of wilful neglect or mistreatment, applicable to organisations and to individuals, should be introduced, but recommends that the Government examine how such behaviour could be prosecuted under existing offences.
The demise of the former NPSA I have never quite understood why the chief NHS clarion of patient safety in the NHS, the National Patient Safety Agency (NPSA), was abolished and its functions incorporated elsewhere. The leadership of NHS patient safety now resides with NHS England, but that body has a number of other functions to manage as well. The NHS, in my view, has lost focus on patient safety since the abolition of the NPSA. However, the Francis report has dramatically refocused the NHS on patient safety. The Committee’s report says:
© 2013 MA Healthcare Ltd
‘The Secretary of State suggested that the Department’s commitment to patient safety remained, despite the decision to eliminate the agency which had as its principal focus the monitoring of patient safety in the NHS: he indicated that the change was intended to “mainstream” a commitment to quality through the NHS system. The Committee is not convinced by this argument. While a commitment to patient safety needs to be promoted throughout the NHS, and is part of the role of the Commissioning Board, responsibility for operating the database of patient safety incidents has been in effect outsourced to an academic institution on a commissioning arrangement which will require renewal at regular intervals.’ The report goes on to say that the purpose of establishing the NPSA as a separate organisation was to create a single focus for concern about patient safety, as one key domain of clinical quality. It was an institutional reflection of the old principle of good medicine: first do no harm. The Committee believes that the abolition of the NPSA reflects a welcome desire to reduce the number of regulatory and quasi-regulatory bodies in an over-crowded field. But the effect of the present arrangements has been to give the appearance that the overall significance of patient safety in health policy has been downgraded, and that the effectiveness of the patient safety function has been compromised. In particular, the location of legacy responsibility with NHS England as the main commissioner of care, rather than with the Care Quality Commission (CQC) as the principal regulator, is surprising. I would agree wholeheartedly with the Committee’s sentiments here. The Committee recommends (as it has done before) that the prime responsibility for monitoring of patient safety practice and data should be a core responsibility of the CQC. The Committee repeats this recommendation, it says, to re-establish the principle that this responsibility should be demonstrably at arm’s length from both the Department of Health (DH) and from NHS England.The Committee further notes that the definitions of patient-safety incidents used by the National Reporting and Learning System (NRLS) focus only on incidents in taxpayer-funded health care.
British Journal of Nursing, 2013, Vol 22, No 20
The definitions should be amended to cover patient-safety incidents in private health care and taxpayer-funded social care services, both of which are the CQC’s responsibility.
Feedback and complaints The Committee agrees with Francis that proper complaintshandling is vital if organisations are to ensure that services change for the better.The Committee recommends that NHS providers promote a culture of openness to complaints and receptiveness to feedback throughout their organisations, and that they should also allow patients and their families to make observations about poor standards of care that will be taken seriously and be of no detriment to the patient. Any staff, the Committee argues, who deliberately treat patients poorly as a result of complaints should be held in breach of a fundamental standard of NHS care, and liable for the consequences. The Government awaits the outcome of the review of complaint-handling in the NHS by Rt Hon Ann Clwyd MP and Professor Tricia Hart. The Committee takes very seriously Francis’s warning that patients in a vulnerable position in hospital may not complain about poor care for fear of adverse consequences, a possibility to which providers should be alert.
Nursing staff in the NHS The Committee acknowledges the scepticism about the Government’s proposal that every student seeking NHS funding for a nursing degree should be required to serve for up to a year as a healthcare assistant as part of a nurse training programme. The concern is that a year may be too long and may deter potential recruits. The Committee recommends that the proposal be fully piloted and carefully evaluated to determine the best maximal length of time for such placements. It is important, the report argues, that other life experiences of potential trainees, including voluntary work, be taken into account under this approach. The Government rejected the proposal by Francis for the establishment of a new category of nurse—the registered older person’s nurse—to recognise the acquisition of specific skills in caring for the elderly. The report states that while the Government is concerned that introducing such a designation might risk putting older persons’ nursing in a silo, the Committee believes that encouraging nurses to develop specialist skills required to care for the elderly is necessary and welcome. It recommends that the acquisition of skills in older persons’ nursing be recognised and certified, and that nurses hold the status of registered older person’s nurse in tandem with other registrations. Other issues that Francis raises are also considered in the report.
Conclusion The Health Committe does not mince its words. Its report contains clear and carefully considered recommendations and observations. It presents a clear window of opportunity for the NHS to put patient safety and interests first, and at the very BJN heart of the NHS. Francis F (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office (TSO), London House of Commons Health Committee (2013) After Francis: making a difference: Third Report of Session 2013–14. TSO, London
1195
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
A
number of reports into patient safety have followed in the wake of the publication of the Francis report into the Mid-Staffordshire NHS Trust (Francis, 2013). The House of Commons Health Committee Report 2013, After Francis, is the latest. In this report, the Health Committee, which is made up of MPs, gives its view on Francis’s principal recommendations. It begins with an introduction to the report and its significance. In the Committee’s view, Francis has: ‘indicated key components of a prevailing culture at Mid Staffs which he characterises as “doing the system’s business”: by definition, this was a culture which tended to prioritise the smooth operation of the healthcare system above the safe and effective care of patients’ The report distils Francis’s 290 recommendations for change in the health and care system: ‘in truth, all can be summed up in one single recommendation—that the culture of the NHS must change in order for the safety and quality of the service, and the public’s confidence in it, to improve’.
An open and transparent NHS According to After Francis, healthcare professionals have an unambiguous professional duty to raise any concerns they may have about the safety and quality of care being delivered to patients with the relevant authorities. Managers do not operate within the same framework of regulated professional obligations, but they should also be expected to raise similar concerns: ‘Trusts and other care providers have a fundamental duty to establish an environment where concerns about patient safety and care quality raised by clinicians or managers are addressed openly and directly’.
Duty of candour John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
1194
The Committee agrees with Francis that the key requirement is for a ‘culture change’ within the NHS to value openness and transparency in all care delivery—not just when things go wrong. The Committee believes that the requirement for openness and transparency is too narrowly drawn in
the NHS Standard Contract. The requirement for candour about mistakes should, it argues, be seen as part of a much wider commitment to an open and accountable service. Challenge and debate about outcomes should occur at all levels of quality achievement and in all contexts of care, not just at the bottom. The Committee believes that if highquality service providers were to set the pace for openness and transparency by making properly anonymised information available on a much improved basis, they would increase the pressure on lower-quality providers to demonstrate that they were matching their standards to the very best. Verbal commitments to high-quality standards are hollow if no effective steps are taken to monitor performance. The Committee also believes that the new formulation in the NHS Constitution, explaining the duty of candour, substantially understates the importance of a more open culture in the NHS. Commissioners and providers should be under a duty of openness about the full range of outcomes achieved, not just about examples of patient harm. Francis argued for a statutory duty of candour owed by providers to patients. The review of patient safety in England, led by Professor Don Berwick, also supports a statutory duty of candour on this model, but it has reservations about its scope, since a requirement for automatic reporting of ‘every error or near miss’ could lead to more bureaucracy and detract from patient care. Francis also argued for a statutory duty on healthcare workers to report beliefs or suspicions about serious incidents to employers. The Committee is not persuaded that a statutory duty defined in secondary legislation, operating in addition to existing contractual duties and professional obligations, will necessarily be effective in achieving cultural change on the scale the NHS needs. It is concerned too that insufficient attention may have been given to how these proposed new arrangements will interact with existing processes.
Fundamental standards of healthcare and patient safety On fundamental standards of healthcare and patient safety, the Committee agrees with Francis that clear, unambiguous standards should be established in such a way that patients, relatives, clinical and auxiliary staff and managers can immediately recognise unacceptable care and take appropriate action. Any breach, the report states, should be treated seriously and investigated thoroughly, but regulatory consequences should be proportionate and focus on analysis and remedy of the circumstances that led to the breach. Where breaches of these standards risk harm to patients, or lead to death or serious injury, the breach should be treated as a criminal matter. The Committee notes the Berwick Review’s recommendation
© 2013 MA Healthcare Ltd
John Tingle discusses the House of Commons Health Committee report, After Francis
British Journal of Nursing, 2013, Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety that an offence of wilful neglect or mistreatment, applicable to organisations and to individuals, should be introduced, but recommends that the Government examine how such behaviour could be prosecuted under existing offences.
The demise of the former NPSA I have never quite understood why the chief NHS clarion of patient safety in the NHS, the National Patient Safety Agency (NPSA), was abolished and its functions incorporated elsewhere. The leadership of NHS patient safety now resides with NHS England, but that body has a number of other functions to manage as well. The NHS, in my view, has lost focus on patient safety since the abolition of the NPSA. However, the Francis report has dramatically refocused the NHS on patient safety. The Committee’s report says:
© 2013 MA Healthcare Ltd
‘The Secretary of State suggested that the Department’s commitment to patient safety remained, despite the decision to eliminate the agency which had as its principal focus the monitoring of patient safety in the NHS: he indicated that the change was intended to “mainstream” a commitment to quality through the NHS system. The Committee is not convinced by this argument. While a commitment to patient safety needs to be promoted throughout the NHS, and is part of the role of the Commissioning Board, responsibility for operating the database of patient safety incidents has been in effect outsourced to an academic institution on a commissioning arrangement which will require renewal at regular intervals.’ The report goes on to say that the purpose of establishing the NPSA as a separate organisation was to create a single focus for concern about patient safety, as one key domain of clinical quality. It was an institutional reflection of the old principle of good medicine: first do no harm. The Committee believes that the abolition of the NPSA reflects a welcome desire to reduce the number of regulatory and quasi-regulatory bodies in an over-crowded field. But the effect of the present arrangements has been to give the appearance that the overall significance of patient safety in health policy has been downgraded, and that the effectiveness of the patient safety function has been compromised. In particular, the location of legacy responsibility with NHS England as the main commissioner of care, rather than with the Care Quality Commission (CQC) as the principal regulator, is surprising. I would agree wholeheartedly with the Committee’s sentiments here. The Committee recommends (as it has done before) that the prime responsibility for monitoring of patient safety practice and data should be a core responsibility of the CQC. The Committee repeats this recommendation, it says, to re-establish the principle that this responsibility should be demonstrably at arm’s length from both the Department of Health (DH) and from NHS England.The Committee further notes that the definitions of patient-safety incidents used by the National Reporting and Learning System (NRLS) focus only on incidents in taxpayer-funded health care.
British Journal of Nursing, 2013, Vol 22, No 20
The definitions should be amended to cover patient-safety incidents in private health care and taxpayer-funded social care services, both of which are the CQC’s responsibility.
Feedback and complaints The Committee agrees with Francis that proper complaintshandling is vital if organisations are to ensure that services change for the better.The Committee recommends that NHS providers promote a culture of openness to complaints and receptiveness to feedback throughout their organisations, and that they should also allow patients and their families to make observations about poor standards of care that will be taken seriously and be of no detriment to the patient. Any staff, the Committee argues, who deliberately treat patients poorly as a result of complaints should be held in breach of a fundamental standard of NHS care, and liable for the consequences. The Government awaits the outcome of the review of complaint-handling in the NHS by Rt Hon Ann Clwyd MP and Professor Tricia Hart. The Committee takes very seriously Francis’s warning that patients in a vulnerable position in hospital may not complain about poor care for fear of adverse consequences, a possibility to which providers should be alert.
Nursing staff in the NHS The Committee acknowledges the scepticism about the Government’s proposal that every student seeking NHS funding for a nursing degree should be required to serve for up to a year as a healthcare assistant as part of a nurse training programme. The concern is that a year may be too long and may deter potential recruits. The Committee recommends that the proposal be fully piloted and carefully evaluated to determine the best maximal length of time for such placements. It is important, the report argues, that other life experiences of potential trainees, including voluntary work, be taken into account under this approach. The Government rejected the proposal by Francis for the establishment of a new category of nurse—the registered older person’s nurse—to recognise the acquisition of specific skills in caring for the elderly. The report states that while the Government is concerned that introducing such a designation might risk putting older persons’ nursing in a silo, the Committee believes that encouraging nurses to develop specialist skills required to care for the elderly is necessary and welcome. It recommends that the acquisition of skills in older persons’ nursing be recognised and certified, and that nurses hold the status of registered older person’s nurse in tandem with other registrations. Other issues that Francis raises are also considered in the report.
Conclusion The Health Committe does not mince its words. Its report contains clear and carefully considered recommendations and observations. It presents a clear window of opportunity for the NHS to put patient safety and interests first, and at the very BJN heart of the NHS. Francis F (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office (TSO), London House of Commons Health Committee (2013) After Francis: making a difference: Third Report of Session 2013–14. TSO, London
1195
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
