Thursday, February 27

PATIENT-CENTRED CULTURE:
HOW TO GET IT AND WHAT TO AVOID:
AN EXPERIENCE OF THE NHS
Robert Francis Q...
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Background
Why a public inquiry?
What went wrong
Reasons for failure
Remedies
Some background
The National Health
Service
Free healthcare at the point of use
 63.2 million UK residents entitled
 > 1.7 million staff...
Patients on the edge not at the centre

National Quality Board – Review of Early Warning Systems in the NHS, Feb 2010
Stru...
The hospital
Records
office

Union reps office

CEO office

Cooling towers–
Badenoch Inquiry
1986

6

© 2013 Robert Franci...
Two inquiries and more…
Initial concerns
HSMR – all deaths: the muffled drumbeat
Financial
Year

Admissions

Observed
Observed Expected - Expected...
The people who who were not
listened to..

9

©2013
Robert
Francis QC
For Eversheds internal use only

10
Pre & post Francis… and then…
One off or common?
Review into the quality of care and treatment
provided by 14 hospital trusts in England:
overview repor...
What went wrong…
A problem of training, attitude, leadership?
She had got a cloth, like a J-cloth, and she
cleaned the ledges and she went ...
... The suffering from neglect

15
Complaints

©2013 Robert Francis QC

1st Mid Staffordshire report page 273

16
A report on a whistleblowers
complaint
The investigation has found evidence of poor leadership
and management and of poor ...
An internal lawyer’s report
Systemic failure of safety?

Extract from Trust investigation report into a death in April 200...
What a trainee doctor observed
Insufficient nursing staff
 No effective nurse leader
 Managerial bullying of nurses to m...
A Royal College report
A dysfunctional surgical department
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Surgical Department dysfunctional and lacking ef...
The cost of inaction
RCS report two years later
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Poor judgement and decision-making
Lack of current knowledge an...
Leadership denial
Q. It [the large number of people complaining about the
same things] might be a reflection that the same...
Reasons for failure
A negative
culture?

PRESSURE
Reorganisation
Targets
Finance
FT status
Jobs

REACTION
Fear
Low morale
Isolation
Disengagem...
COMMUNITY DENIAL

Ambulance driver
abuses Mid Staffs
Campaigner Julie Bailey
on Facebook
“ I hope you suffer a lifethreate...
Effect on staff morale of work pressure
I mean in some ways I feel ashamed because I
have worked there and I can tell you ...
“You walk away”
The nurses were so under-resourced they were working
extra hours, they were desperately moving from place ...
Professional self interest
Perhaps I should have been more forceful in my statements,
but I was getting to the stage where...
LEADERSHIP?
Many doctors express fear about the consequences, and this
inhibits us from doing what we know to be right. Th...
Isolation through lack of candour
With regards to the content of reports for the Coroner ... as
reports are generally read...
Leadership change – where does the buck stop?
Ministers

Permanent
Secretaries

Chief
executives?
Regulators

Commissioner...
Barriers to Board receiving the truth
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Board focus on “strategic” not “operational”
Inadequate information...
Lack of transparency and
candour: some examples
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Misinformation to regulators
 Told mortality not a problem
...
What chance coordinated action?

National Quality Board – Review of Early Warning Systems in the NHS, Feb 2010
How do you change an unhealthy
culture
… or protect a healthy one?

©2013 Robert Francis QC
Recommendations
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


Common values
Fundamental standards
Openness, transparency and candour
Compassionate, carin...
Fundamental standards
What the public see as absolutely essential
What the professions accept can be achieved
Enshrined in...
Openness, transparency &
candour
Openness: enabling concerns and
complaints to be raised freely and
fearlessly, and questi...
Openness




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
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

Welcome complaints and concerns
Gagging clauses to be banned
Independent investigation of seriou...
Compassionate Caring Committed Nursing
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Aptitude assessment on entry
Hands on experience a prescribed requ...
Strong patient centred leadership
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Recruit and train for values
 Staff college open to all candidates and recruits
 Vo...
ACCURATE USEFUL RELEVANT
INFORMATION
Individual and collective responsibility to
devise performance measures
 Patient, pu...
Reasons for optimism
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Commitment to all inquiry’s objectives
Acceptance of most of recommendations
Senio...
… and a lot of activity…
Schwartz Rounds to
support staff and foster
compassion

Every hospital patient will
get point-of-...
And finally…
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Patient-Centred Culture: How to Get It and What to Avoid - An Experience of the NHS

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This presentation was the first Plenary Speaker on Thursday morning of the Quality Forum 2014

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Patient-Centred Culture: How to Get It and What to Avoid - An Experience of the NHS

  1. 1. Thursday, February 27 PATIENT-CENTRED CULTURE: HOW TO GET IT AND WHAT TO AVOID: AN EXPERIENCE OF THE NHS Robert Francis QC Serjeants’ Inn Chambers 85 Fleet Street London EC4Y 1AE
  2. 2.      Background Why a public inquiry? What went wrong Reasons for failure Remedies
  3. 3. Some background
  4. 4. The National Health Service Free healthcare at the point of use  63.2 million UK residents entitled  > 1.7 million staff [1.3m in England]  1 million patients per 36 hours  2013/14 DH budget £114.1 billion  2013/14 total budget £339.2 billion  Health roughly 33% total budget  NHS England; Central Government Supply Estimates 2013-14, April 2013
  5. 5. Patients on the edge not at the centre National Quality Board – Review of Early Warning Systems in the NHS, Feb 2010 Structures and processes for safeguarding quality
  6. 6. The hospital Records office Union reps office CEO office Cooling towers– Badenoch Inquiry 1986 6 © 2013 Robert Francis QC
  7. 7. Two inquiries and more…
  8. 8. Initial concerns HSMR – all deaths: the muffled drumbeat Financial Year Admissions Observed Observed Expected - Expected Deaths Deaths deaths 95% CIs around HSMR 95% CIs around observed deaths 95% CIs around Obs-Exp deaths HSMR High Low High Low High Low 1996/97 11,088 774 782 -8 99 106 92 831 720 48 -62 1997/98 10,954 765 702 63 109 117 101 821 712 119 10 1998/99 11,635 794 733 61 108 116 101 851 740 118 7 1999/00 11,776 801 754 47 106 114 99 858 746 105 -7 2000/01 11,496 718 670 48 107 115 99 772 666 102 -4 2001/02 12,156 821 736 85 112 119 104 879 766 143 30 2002/03 12,398 794 674 120 118 126 110 851 740 177 66 2003/04 12,315 841 668 174 126 135 118 900 785 232 118 2004/05 13,781 882 766 116 115 123 108 942 825 176 59 2005/06 14,073 878 707 171 124 133 116 938 821 231 114 2006/07 16,569 870 683 187 127 136 119 930 813 247 130 2007/08 1996/72007/8 16,433 947 813 134 116 124 109 1,009 888 196 74 154,674 9,885 8,688 1,197 114 116 112 10,082 9,691 1,394 1,003 Source: Professor Jarman
  9. 9. The people who who were not listened to.. 9 ©2013 Robert Francis QC
  10. 10. For Eversheds internal use only 10
  11. 11. Pre & post Francis… and then…
  12. 12. One off or common? Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report Professor Sir Bruce Keogh KBE CQC National report on dignity and nutrition review published 13 October 2011 This review was a targeted inspection programme of NHS hospitals. It looked at whether older people are treated with respect and whether they get food and drink that meets their needs.
  13. 13. What went wrong…
  14. 14. A problem of training, attitude, leadership? She had got a cloth, like a J-cloth, and she cleaned the ledges and she went into the wards, she walked all round the ward with the same cloth, wiping everybody’s table and saying hello, wiping another table and saying hello. Came out of there, went into the toilets and lo and behold, she cleaned the toilets with the same cloth, and went off into the next bay with the same cloth in her hand. You can’t believe what you saw, you really couldn’t believe what you saw. A visiting relative in 2006 ©2013 Robert Francis QC 14
  15. 15. ... The suffering from neglect 15
  16. 16. Complaints ©2013 Robert Francis QC 1st Mid Staffordshire report page 273 16
  17. 17. A report on a whistleblowers complaint The investigation has found evidence of poor leadership and management and of poor nursing care on Ward 3 … There is a strong view on the Ward that failings are due to the poor staffing levels and therefore excusable. The culture on the ward appears to allow for support of this view … Nobody at directorate/Trust level appears to have taken responsibility for monitoring/auditing to ensure that basic nursing standards/patient care needs are met … There appears to be a lack of commitment at the highest level in the Trust to tackle these problems Barry report August 2005: Public Inquiry Report page 68 17 ©2013 Robert Francis QC
  18. 18. An internal lawyer’s report Systemic failure of safety? Extract from Trust investigation report into a death in April 2007 ©2013 18 Robert Francis QC
  19. 19. What a trainee doctor observed Insufficient nursing staff  No effective nurse leader  Managerial bullying of nurses to meet targets  Capacity issues in wards  Dysfunctional clinical leadership  Proposed remedy of recruiting emergency physicians worse than cure  ©2013 Robert Francis QC 19
  20. 20. A Royal College report A dysfunctional surgical department       Surgical Department dysfunctional and lacking effective leadership; Colorectal department dysfunctional since 2003. No working relationship between surgeons in the team: ... no cohesion within the department ... makes it very difficult for other members of the team to function in a satisfactory way Multidisciplinary team meetings compromised by disagreement; No departmental protocols on bowel preparation, antibiotic usage and postoperative management; Surgeon had little or no insight into the problems over 4 years Extract from RCS report October 2007. Public Inquiry report page 111-112 ©2013 Robert Francis QC 20
  21. 21. The cost of inaction RCS report two years later      Poor judgement and decision-making Lack of current knowledge and suboptimal postop care Some care “grossly negligent”. The surgical division “dangerous” Alternative to immediate urgent action was the closure of the department. The ... Report refers to so many badly managed cases that it would be difficult to single out any particular surgeon RCS report 2009. Public Inquiry Report page 1027-1028 ©2013 Robert Francis QC 21
  22. 22. Leadership denial Q. It [the large number of people complaining about the same things] might be a reflection that the same sort of poor care was happening to a number of different people. Do you accept that? A. I think it’s much, much more likely that the reason a huge number of people didn’t find anything uniquely dreadful is that there was nothing uniquely dreadful to find out. Q. And that is still your belief? A. Yes Evidence of former Chair of Trust to Public Inquiry ©2013 Robert Francis QC 22
  23. 23. Reasons for failure
  24. 24. A negative culture? PRESSURE Reorganisation Targets Finance FT status Jobs REACTION Fear Low morale Isolation Disengagement No openness HABITUATION Tolerance Denial External reassurance Someone else’s problem BEHAVIOUR Uncaring Unwelcoming Bullying Keeping head down ©2013 Robert Francis QC 24
  25. 25. COMMUNITY DENIAL Ambulance driver abuses Mid Staffs Campaigner Julie Bailey on Facebook “ I hope you suffer a lifethreatening illness at night where you have to travel further than you should do because your local hospital is closed (your fault).” Hospital whistleblower hounded out of town “Thank you for closing Stafford hospital, Ha, Ha, Ha, you better now spend more time watching your mother’s grave.” ©2013 Robert Francis QC 25
  26. 26. Effect on staff morale of work pressure I mean in some ways I feel ashamed because I have worked there and I can tell you that I have done my best, and sometimes you go home and you are really upset because you can’t say that you have done anything to help. ... you have answered buzzers, you have provided the medical care but it never seemed to be enough. There was not enough staff ... to provide everything that a patient would need. You ... were just skimming the surface and that is not how I was trained. A nurse ©2013 Robert Francis QC 26
  27. 27. “You walk away” The nurses were so under-resourced they were working extra hours, they were desperately moving from place to place to try to give adequate care to patients. If you are in that environment for long enough, what happens is you become immune to the sound of pain. You either become immune to the sound of pain or you walk away. You cannot feel people’s pain, you cannot continue to want to do the best you possibly can when the system says no to you, you can’t do the best you can. A doctor who started in A&E in October 2007 ©2013 Robert Francis QC 27
  28. 28. Professional self interest Perhaps I should have been more forceful in my statements, but I was getting to the stage where I was less involved and I was heading to retirement … I did not have a managerial role and therefore I did not see myself as someone who needed to get involved. Perhaps my conscience may have made me raise concerns if I had been in a management role, but I took the path of least resistance. In addition … most of my patients were day cases and there was less impact on those patients. There were also veiled threats at the time, that I should not rock the boat at my stage in life because, for example, I needed discretionary points or to be put forward for clinical excellence awards Evidence given to the Public Inquiry 28 ©2013 Robert Francis QC
  29. 29. LEADERSHIP? Many doctors express fear about the consequences, and this inhibits us from doing what we know to be right. The answer here is not to criminalise that fear, not to introduce an individual statutory duty of candour if you will, but to remember that for speaking up to be meaningful, employers must listen to patients’ and doctors’ concerns. Extract from speech of Dr Mark Porter to BMA Annual Conference 24 June 2013 http://bma.org.uk/about-the-bma/how-we-work/annual-representative-meeting2013/arm-2013-monday/arm-2013-porter-speech 29 ©2013 Robert Francis QC
  30. 30. Isolation through lack of candour With regards to the content of reports for the Coroner ... as reports are generally read out in full at the Inquest and the press and family will be present, with a view to avoiding further distress to the family and adverse publicity I would wish to avoid stressing possible failures on the part of the Trust ... In my opinion it is self evident from your report that that is probably the case but I feel such a concluding statement may add to the family’s distress and is not one which I would wish to see quoted in the press Solicitor’s request to consultant to change report: Public Inquiry Report page 185-186 ©2013 Robert Francis QC
  31. 31. Leadership change – where does the buck stop? Ministers Permanent Secretaries Chief executives? Regulators Commissioners Directors Inquiries 31 ©2013 Robert Francis QC
  32. 32. Barriers to Board receiving the truth       Board focus on “strategic” not “operational” Inadequate information to Board  Complaints not reported  Incident investigations not reported  Mortality stats discounted Weak clinical representation  1 doctor, 1 nurse  Weak consultants committee Reliance on external oversight  Star ratings, NHSLA ratings, FT authorisation Poor staff relations  Incident reports re staff shortages ignored  Concerns raised by staff discounted Financial pressure  Resort to staff reduction  No risk assessment  Corporate optimism
  33. 33. Lack of transparency and candour: some examples      Misinformation to regulators  Told mortality not a problem  “Quality is our business”  “We are in the premier league now” Unfavourable reports not shared  A&E incident report for coroner required to be modified and not sent  RCS report not mentioned to regulator Formulaic responses to complaints and “action plans” More weight to favourable than unfavourable data Inadequate weight given to risk to patients  No urgency to correct nurse skill mix and patient/nurse ratio  Deficiencies in A&E tolerated  No urgent action taken re Royal College of Surgeons report
  34. 34. What chance coordinated action? National Quality Board – Review of Early Warning Systems in the NHS, Feb 2010
  35. 35. How do you change an unhealthy culture … or protect a healthy one? ©2013 Robert Francis QC
  36. 36. Recommendations        Common values Fundamental standards Openness, transparency and candour Compassionate, caring, committed nursing Strong patient centred healthcare leadership Accurate, useful and relevant information Culture change not dependent on Government ©2013 Robert Francis QC 36
  37. 37. Fundamental standards What the public see as absolutely essential What the professions accept can be achieved Enshrined in regulation by Government Compliance measured by evidence based methods Policed by CQC [including governance required to meet these standards]  Distinguish from enhanced quality standards subject to commissioning  Serious response/reaction to persistent/serious failure      ©2013 Robert Francis QC 37
  38. 38. Openness, transparency & candour Openness: enabling concerns and complaints to be raised freely and fearlessly, and questions to be answered fully and truthfully  Transparency: making accurate and useful information about performance and outcomes available to staff, patients, public and regulators  Candour: informing patients where they have or may have been avoidably harmed by healthcare service whether or not asked  ©2013 Robert Francis QC 38
  39. 39. Openness         Welcome complaints and concerns Gagging clauses to be banned Independent investigation of serious cases Involving complainants , staff Real feedback Real consideration by Trust Board Information on actual cases shared with commissioners, regulators, and public Swift and effective action and remedies ©2013 Robert Francis QC 39
  40. 40. Compassionate Caring Committed Nursing         Aptitude assessment on entry Hands on experience a prescribed requirement Standards of training standards, assessment , appraisal for core values and competence to deliver Named nurse [and doctor] responsible for each patient Code of conduct and common training standards for HCSWs Registration requirement for HSCWs plus power to disqualify/share info re concerns Reward good practice; recognise special status of care of elderly Review Knowledge & Skills Framework ©2013 Robert Francis QC 40
  41. 41. Strong patient centred leadership  Recruit and train for values  Staff college open to all candidates and recruits  Voluntary accreditation Leadership by example  Code of conduct prioritising patient safety and wellbeing, candour  Accountability through disqualification for serious breach and deficiencies  Keep possibility of wider regulation under review  ©2013 Robert Francis QC 41
  42. 42. ACCURATE USEFUL RELEVANT INFORMATION Individual and collective responsibility to devise performance measures  Patient, public, commissioners and regulators access to effective comparative performance information for all clinical activity  Improve core information systems  ©2013 Robert Francis QC 42
  43. 43. Reasons for optimism         Commitment to all inquiry’s objectives Acceptance of most of recommendations Senior level candour about concerns  Secretary of State  CQC  Salford Royal NHS Foundation Trust ○ data designed to show if staffing not at expected level Expert led inspections – involving patient experts and clinicians Human factors science concordat [NQB] Published individual level outcomes in 10 specialties Professional engagement  RCP –Future Hospital Commission Front line experience  Entry requirement for nurse training  Civil Servants!
  44. 44. … and a lot of activity… Schwartz Rounds to support staff and foster compassion Every hospital patient will get point-of-contact doctor, Health Secretary Jeremy Hunt will announce Hunt urges consultants to take responsibility Care regulator set to oversee barring scheme for health service directors 23 January, 2014 My patient experience There were frequently significant delays in answering buzzers, helping people to the toilet and providing pain relief. There was a striking difference from shift to shift in the quality … https://maryagnew.blog.gov.uk
  45. 45. And finally…
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