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

‘We have still not moved away from a culture of blame’. So says Robert Francis in his erudite, if voluminous, report into the failings at the Mid Staffordshire NHS Foundation Trust published earlier today.

He gets straight to the point in his report. The culture of the NHS still has too many negative aspects to it:

• a lack of openness to criticism
• a lack of consideration for patients
• defensiveness
• looking inwards not outwards
• secrecy
• misplaced assumptions about the judgements and actions of others
• an acceptance of poor standards
• and a failure to put the patient first in everything that is done.

All this must change, he quite rightly states.

He has some excellent ideas for how this can be achieved. Mercifully, he makes it clear he does not believe that structural change is the answer. He states it is unlikely that any structural change could enhance patient safety, and goes on to make the telling point that within any system, of whatever design, there needs to be a relentless focus on ensuring patient safety.

The most welcome recommendation he makes is that the NHS Constitution should lie at the heart of the changes needed. 'The common values of the service must be enshrined in and effectively communicated by the NHS Constitution, and owned and lived by all members of the service', he states in the report. The Constitution should be the first reference point for all NHS patients and staff. As a member of the Expert Advisory Group on the NHS Constitution working with the Department of Health to modernise and promote a revised Constitution, this is music to my ears.

There are many other recommendations of real merit. For example, he rightly recognises the value of peer review, often neglected in a culture of top down performance management. It has, he says, ‘a far more fundamental role in changing behaviour to ensure a consistent and caring culture throughout healthcare services’.

He also helpfully recognises that there should be an increased focus on a culture of compassion and caring in nurse recruitment, training and education. He makes the valid point that training and continuous professional development for nurses should apply at all levels from student to director. We know how access to this is currently difficult, if not impossible, for many nurses. It will have resource implications but is vital to improve the quality of care.

It is gratifying too to see him recommend that the GMC and the NMC should ensure that patient safety should become the first priority of both medical and nursing training and education.

But as I waded through his report (the executive summary alone extends to 117 pages), I began to wonder: where is the patient in all this? I couldn't help but form an impression that the patient was there to be 'done unto'. In the case of Mid Staffordshire, done unto neglectfully and appallingly. In that context, Francis' quest was to find ways of ensuring that this would never happen again, that the patient in future would be put first, and everything done by the NHS and everyone associated with it should be informed by this ethos. Yet I could not help feeling that, in Francis' vision of the future, the patient remains something of a passive onlooker, not an assertive participant.

Quite properly, he says that, in the future, staff should put patients before themselves; they should do all in their power to protect patients from avoidable harm; and they should be open and honest with patients. Patients should be given information on which to make informed decisions. They, and the wider public, should be involved in decisions, both nationally and locally, about how care and treatment should be provided. Interestingly, specifically in relation to the care of elderly people, he also advocates a greater role for patients' families and carers.

However, nowhere does he say that patients should be involved in decisions about their care and treatment. Nowhere does he make it clear that it is the patients who should be in control. Nowhere does he advocate the encouragement of supported self management. This is a missed opportunity to promote a step change in the way in which care is delivered in the NHS. It runs the risk of an undue reliance on the system getting it right for the patient. We know all too well that this is not enough.

Stephen is Chief Executive at the Health Foundation.