The Francis Report: right diagnosis but will the treatment work?

It will only change when the patient has choice.
They will vote with their feet if an NHS hospital is not good or safe.
The current NHS construct is all wrong for patients but a sinecure for staff

Hopefully this will put patient safety and care at the top of the NHS agenda. Leaders have barely touched on the subject for the past 4 -5 years and as a result it has been impossible to get any traction. As with the banks and their risk management, without visible leadership commitment to address this core issue nothing will happen.

I agree there are missed opportunities here. Patient involvement is the key to culture change and a clear vision of and focus on person centred care.

All NHS Boards must be allowed to act as if , and not just say that, Patient Safety comes First!
Otherwise the public will rightly see their local healthcare organisation as no better than the food / drinks company "who tick their regulatory box" by printing "please drink responsibly" on their 4 can pack of 9% ABV lager.

The general public should be free to demand better, safer care, but also understand / accept that this is made no easier with government austerity cuts...

The question of values deserves a wider discussion. We might assume that these are contained within professional codes or administrative guidelines, but this awful example demonstrates otherwise. The interaction between patients and professionals would benefit from a stronger values-based paradigm. Trust and mutual accountability do need easily emerge from legislation. Just look at the banking industry...

Mid-Staffs is an extreme example of what happens when policy foregrounds cost - efficiencies and data gathering (without data using) and with little or no understanding of how organisations function. Regulation is necessary but not sufficient. There is too much emphasis on individual culpability and not enough on examining the systems that underpin the delivery of care. But it's relatively easy to identify problems - harder to implement solutions. Let's focus on supporting a culture of caring backed by awareness of and engagement with systems improvement.

Where is the patient, indeed.
The patient not only requires a voice, but power.
As Martin Luther King said:
"Love without power is mere sentimentality: love with power is justice."
However, I see this as being very difficult to achieve unless we have a patients' champion - a patients' matron - whatever the terminology.
Someone who is able to go round the wards, who is not attached to the NHS, but who will be able to talk to patients, note points of concern that are repeatedly raised, and be able to report them to CEOs.. An Advocate - an enabler - would go a long way.

Robert Francis, having spent months swimming in an NHS culture of heirarchical paternalism, is like a fish that fails to spot it is in water.
I spent a year working with a CCG to embed shared decision making and co-created outcome measures into integrated care for long term conditions.
What happened....
http://www.alderoak.co.uk/20279.html

I do wonder what will (or won't) happen to make a difference?
I have found enormous indifference from many when writing and talking about this sort of thing a decade ago. Maybe we now have a ‘burning platform’?

I do worry many in healthcare still don’t get it – or don’t care, including clinical staff. I saw this personally in December last year when going to A&E with a freind.

Turning a hospital from a place desgned for the advancement of personal careers for staff into a real patient focused institution will be hard. I liked Christina Patterson’s piece in The Independent this week. It gave me hope.

My fear is the whole post-Francis era becomes bureaucratised into reports and big consultancy. For me the key is asking, passionately and continuously, what more could we do to get thigns right? I am convinced if the right questions are curiosly asked lots will fall into place as people learn together.

Stephen is right to mention training, and continuing professional development as opportunities to embed a 'culture of compassion'. All too often 'competence' is defined (and limited) by the knowledge and skills that a person has. True competence requires the right knowledge, skills, attitudes and behaviours. Without these latter 'human factors' you are only ever viewing half of the jigsaw. NHS Mids and East have addressed this in catheter infections (free to download). Also, when we talk about leaders in the NHS, we need to remember that not all leaders have the word 'leader' or 'manager' in their job title - some of the best leaders are informal mentors - they need to be empowered to do so.

It will change when Trusts STOP PAYING /REWARDING/ PATIENTS to complain against targeted individuals!

Decisions & conclusions are made via 'via the whispering gallery' rampant in all NHS Trusts!

The recent Francis Report comprehensively documents modern health care ‘gone bad.’ The report portrays and documents a ‘system perfectly designed to get the results it gets.’ Woven into the report, its recommendations and some early responses to the report are theories about how ‘good’ care is created and they deserve to be carefully examined.

I have formed my own professional values in diverse work as a physician over the past four and one-half decades. I began as a General Pediatrician. Subsequently I learned in my work as a clinical practice organizational leader, a health services researcher, a public health administrator, a governing director and for the last three-plus decades as a developer and teacher of approaches to the measurement and improvement of the quality, safety and value of health care. The settings for my work have been largely in the U.S., but have also included work in Norway, Sweden and more recently the Health Foundation in the U.K. I am an ‘outsider’ to many in the UK, but an ‘insider’ to a lifetime of work in the world of quality, safety and value improvement of health care and to W. Edwards Deming’s thinking about improvement.

In that context, I offer five reflections:

1. Health care is at the same time a simple, complicated and complex phenomenon.

To the extent that evidence supports policy, incentives—particularly financial incentives—work best for simple things and tend to have unreliable (including opposite) effects on desired change in complex things.

Designers of incentive programs are clear that to work constructively on even simple things, incentives must focus on just a few variables to achieve maximum effect. Consider the situation of a pediatric doctor who needs to do hundreds of different things well in a day: incentivizing performance about three of them will distort the work on the rest of the good work of that professional, if its intended effect is realized. That type of incentive-induced distortion of ‘good’ health professional work is documented in the Francis report.

Financial incentives to ‘care better’ for another human being have yet to demonstrate their effectiveness under the widely varying circumstances of the real world—current public & political rhetorical volume notwithstanding.

Using ‘simple’ solutions to ‘complex’ problems may be good short-term politics, but is not likely very effective long-term policy.




2. Measurement is a reductive art.

When numbers are used to describe a service or a product, they are usually related to discrete aspects or attributes of that service or product. Deming, a statistician, was keen to encourage people to use measurement for learning and for the improvement of what they were ‘making.’ Lord Kelvin was on to something when he reminded us that until we can measure something, our knowledge of it is superficial.

But today we live in a festival of measurement which often obscures the basics of good measurement, disconnects measures from their designed use and diminishes the learning that might arise from good measures used well. Further, they invite the assumption that physical distance between the care and those trying to understand, monitor it is inconsequential. No measures substitute for direct observation by experienced, sensible, sensitive observers.

Paying health professionals for the presence or absence of certain measured attributes of a service or product is very risky. It risks distorting the ‘goodness’ of a given service to those attributes measured. Measuring the professional performance involved in creating a service for diverse individuals and paying on the presence/absence of one of those attributes is tempting, but as the Francis Report documents can confuse what is important in the work and can actually harm patients.


3. Outcomes matter when trying to improve the systems and processes of care related to them.

Health outcomes are partly related to the professionals and their work, partly related to the natural history of the relevant disease biology, partly related to the genetic make-up of the individual and partly related to the social support and structures that contribute to the context of the person with the illness. To pretend that it is simpler than that unfortunately contributes to a sense of professional futility about the urgent need to scientifically engage the improvement of health care.

A shared conversation about the reality of how outcomes are produced, modified is fundamental to attracting the obligatory full professional participation in the needed process(es) of change.


4. Rapid-cycle leader turnover in health care organizations usually contributes to a preservation of the status quo in those organizations.

The work of health care today occurs in systems. Designing, introducing, evaluating, and re-designing change to achieve desired results in the performance of those systems requires leadership that evokes a culture of trust and respect. Leaders must attract the energies of those needed to make and secure the needed changes.

External frustrations with change requiring varying lengths of time lead to shorter-length leadership cycles and an internal avoidance of changing the ‘hard’ things to change and an overdependence on policies of ‘leader replacement’ to achieve needed systemic change.

Rapid-cycle replacement of leaders may seem politically wise, but the reality is that short-term leaders have difficulty making big change in complex organizations. The Francis report suggests that ‘hard-to-change,’ ‘big’ things probably need to be changed.


5. ‘Patient-centric’ care is an inviting label for health care that can acknowledge the centrality of focus on the patient’s needs, but can also invite a distorted view of professional work.

It can also make us think that ‘care’ is some form of a professionally created patient-related ‘object’ for patient-consumers to be ‘satisfied with.’ Professionals don’t make health care objects.

As Lawrence Henderson observed in 1936: ‘Professionals and patients are members of the same system.’ Patients and professionals are in relationship working together to co-produce reductions in the burden of illness.

Until we begin to honor the wisdom of an ancient teacher, Abba Felix: ‘We must create spaces in which we practice obedience to the truth,’ we are not likely to learn together about the requirements for real change in health care. We will not make lasting progress and may contribute to the need for even more inquiries about yet more horrific situations.

Paul Batalden, M.D.
Emeritus Professor, The Dartmouth Institute of Health Policy and Clinical Practice
Dartmouth Medical School, USA

Chair, Improvement Science Development Group
The Health Foundation, London

This report came too late for my mother who died in appalling circumstances in a Hampshire hospital three years ago. She spent three months on a ward full of nursing staff with no compassion, no ability to treat with dignity, or having any feeling for the elderly who would probably end their days there. In fact I can say some of those staff were downright cruel. Is this report enough? The problem is widespread, not just limited to places like Staffordshire. It is like a cancer eating through the NHS system. Gone are the days when the nursing staff would stand by your bed and hold your hand when you weren't feeling up to that days pain and suffering. In fact on some occasion's that pain and suffering is now inflicted by the very people who are supposed to be caring for you! Am I cynical? I have seen enough in that three months waiting by my mothers bed to say that I have a very dim view of the nursing staff, including the consultant who treated her, because they should not have branched in to geriatrics if that is how they feel the elderly deserve to be treated at end of life! God help us all when it is our turn!

Although Francis could and should have said more about empowering patients, the vast majority of his findings and recommendations stem directly from him taking on board and understanding patient experience and what needs to change from a patient centric point of view. Especially the statutory Duty of Candour, which surely the Government must now agree to??? He could and should have said more about accountability as well which would have avoided the current obsession with personal accountability at the expense of focussing on the recommendations. But now is the time to insist on the implementation of the recommendations he has made, not to pick over what he might have said, or allow politicians to side step the actual recommendations.