© Nuffield Trust 17 February 2014

The Francis Report: one year on The response of acute trusts in England

Ruth Thorlby

Judith Smith

Sally Williams

Mark Dayan

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What we did

Explored the responses of acute hospital trusts in England to the Francis Report (February 2013)

Aim: to understand the significance for hospitals of the Francis Inquiry findings, in the context of an evolving and complex environment – rising demand, finite resources, increasing regulatory scrutiny

Result: provides a snapshot of the impact of the Francis Inquiry

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Rapid review of board papers from 37 trusts

Electronic survey of chairs

and chief executives at

158 acute trusts in England – 53

responses

48 in-depth interviews with staff at 5 case

study sites (across three

regions in England)

Robert Francis QC – adviser to the project team

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What we didn’t do

• Establish whether or not acute trusts acted on specific recommendations

• Explore whether good intentions and reports of initiatives/actions had translated into change and improvement

• Validate the perceptions of senior leaders in trusts with external bodies responsible for oversight of hospitals

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Survey suggests there is lots to be optimistic about…

94% of boards reported having

assigned someone at board level to lead response to Francis Report – most often director of nursing,

but in fifth of trusts it was the CE

82% reported taking new actions in

response to Francis – most commonly

reviewing/increasing nurse numbers,

improving complaints handling, and better

engagement with staff and patients

93% reported that they already had

work underway on many of the relevant recommendations

when the report was published

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Case study interviews suggest the Francis Report has added impetus to efforts to make quality of

care the first priority…

Recommendations for improving

organisational culture through openness, transparency and

candour have been well received

Greater emphasis on listening to staff,

whistleblowing, and clinical leadership,

reviewing nurse staffing levels and

skill mix

Initiatives to improve the range of data

about quality of care – particularly at ward level and often in real

time – and use of peer reviews and

mock ‘Keogh’ visits

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But profound tensions still exist…

Quality vs finance: Senior leaders reported that the Francis report has reinforced efforts to prioritise quality of care as equal to, or ahead of, financial matters…..but ongoing tension between the two goals.

E.g. meeting financial goals and ensuring safe staffing levels

Standards measured most assertively/frequently vs internal quality activity: Some felt that the continuing desire of the central NHS management system to be assured that hospitals were meeting financial and other performance targets, could undermine work to improve and manage services more widely

E.g. particularly an issue for 4hr A&E target

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A burdensome regulatory approach is reported…

• Trusts reported greater pressure from external bodies seeking assurance of quality in the wake of the Francis report, including national regulators, NHS England’s local area teams and clinical commissioners

• The collection and validation of data needed by external bodies was proving onerous for some hospitals

• Leaders described a burdensome regulatory approach that seemed to be at odds with efforts to develop an open quality-focused culture

• Concerns were raised about insufficient coordination of monitoring and performance management of local trusts

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The culture of external performance management…

• The culture of the external performance management and regulation system still felt punitive and overbearing at times

• Some reported that the focus on financial balance still appeared to be uppermost in the minds of some commissioners and regulators

• Some perceived that a shift in values of the wider system – to value what is happening to patients as the most fundamental principle – had not yet been demonstrated

• A strong message from some interviewees was that efforts to bring about cultural change internally could be undermined by the performance management of acute trusts

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What some people told us…

‘What the NHS response to Francis utterly misses is that external inspection and assurance should not be relied upon, yet nationally most of the response de-powers boards and inflicts upon them, endless duplicative models of assurance.’

(Survey respondent)

‘I’ve never, in my whole career, felt more regulated.’

(Chief Executive, Case study trust)

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Achieving Genuine Cultural Change

…particularly in relation to staff feeling able to raise concerns

without fear

Managing The Tensions Between Quality And Finance

…as financial pressures mount across the public sector

Ensuring The Correct Levels Of Qualified Nurses

…in the context of financial constraints

Allowing Trusts Space To Develop And Learn From Locally Owned

Quality Assurance Activity

…and for national bodies (e.g. CQC, Monitor) to consider how these should relate to their own

assessments of quality and safety

Challenges arising from Francis…

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Gaps highlighted by this research…

The ‘health’ of the wider NHS system: trusts are being

encouraged to use ‘cultural barometers’ to assess the health of

their own organisations

who is assessing the behaviour and functioning of the wider

NHS system, to establish whether failings identified by the

Francis report have been rectified?

Leadership at health economy level: a leadership gap in the

system was identified at the level of the local health economy

who should take the lead at the level that matters most?

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What’s needed…

Starter for ten:

• Measuring the culture of the wider system

• Tracking how far hospitals prioritise quality and safety

• Publishing and benchmarking a suite of measures of patient experience/quality

• Assessing staff engagement across and within trusts

What are your thoughts on what else is needed?

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