Mid-Staffs and the Francis Report

It couldn't happen here...

Could it?

Dr Jonathan Treml

Consultant Geriatrician

Queen Elizabeth Hospital, Birmingham, UK

Jonathan.Treml@uhb.nhs.uk

CREPS Seminar, Monash University, April 2014

NOTE

This presentation is a personal opinion and does

not reflect the views of my employer, NHS England

or any other organisation with which I am

connected.

"There is a theory which states that if ever anybody

discovers exactly what the Universe is for and why

it is here, it will instantly be destroyed and be

replaced with something even more bizarre and

inexplicable."

Douglas Adams

"There is another theory which states that this has

already happened"

Douglas Adams

I work for NHS England

What can Australian healthcare learn from

a small country like the UK?

Something, perhaps…

"Let each person tell the truth from their own experience"

Florence Nightingale

"Better to pull your own trousers down in public, not

someone else's"

Alistair Main

A fall in a bathroom

• Amy was 95 years old with heart failure, severe

aortic stenosis, balance impairment, mild

cognitive impairment

• Admitted with severe pneumonia, immobile

• Responded to treatment, mobility improving

• MRSA-positive, so moved into a side room

• Amy needed minimal assistance to stand and walk

• In bathroom, given call bell and advised to call for help

• Got up by herself, washed hands, turned...

• ...and fell, breaking her hip

• High-risk surgical fixation next day

• Sadly, died 2 days later

Local context

• My ward is one of 40, 5 in old building

• 40% of beds are in en suite single rooms

• Curved internal corridors reduce line of sight

• Most wards will have 1 or 2 falls resulting in

severe harm in a year

• How easy would it be for me to know if my ward

was significantly unsafe?

National context

• There are 168 acute hospital trusts in England

• How does a hospital in London, Manchester or

Newcastle learn from experience in Birmingham

or, more importantly, Stafford?

• What about other healthcare systems?

"The very first requirement in a hospital is that it

should do the sick no harm."

Florence Nightingale

Mid-Staffs - What happened • Excess deaths estimated at 400-1200 at Stafford Hospital

between 2005-2009

• 2007 - first evidence that mortality rates were persistently higher than expected based on HSMR

• 2008 - Mid-Staffs board explained that this was a “coding issue”

• This was the 8th highest HSMR in England

• (The 7 trusts with higher HSMR’s were not investigated)

• From 2009, HSMR reduced from 127 to 93 in 2 years

What happened

• Whistleblowers raised multiple concerns

• Concerns from relatives of deceased patients

• Reports of low standards of care, particularly with

regards to nutrition, hydration, hygiene and dignity

• Low staffing levels (partly) due to cost-saving to

achieve financial targets

Cure the NHS

• Campaign started by Julie Bailey after her mother died at

Stafford Hospital in 2007

• Julie and her family witnesses multiple instances of poor

care

• Soiled sheets, lack of pain relief, lack of assistance to eat

and drink

• Other families joined the campaign

• Pushed for public inquiry

Investigations

• 2009 - Healthcare Commission investigation

• Confirmed many of the concerns

• 2010 - First Francis Inquiry

• Limited remit, but independent

• 2013 - Second Francis Inquiry - Francis Report

• Full public inquiry 2010-13

The Francis Report

1800 pages, 290 Recommendations

Key findings

• Mid-Staffs board were ultimately at fault for chasing

(financial) targets over quality of care and for failing to

listen to complaints

• Staffing levels were inadequate in some areas

• Regional health authority did not have adequate systems to

identify performance concerns

• Regulators criticised for being slow to identify issue

• Department of Health criticised for putting politics above

patients

Who was held responsible?

• Apparently nobody

• Chief Exec had already moved on

• Regional Health Authority CEOs in new posts

• Regulatory body also changed (now CQC)

• New Government by time of report

• Francis (correctly) believed that blaming individuals would

perpetuate a myth that changing individuals was the

solution, when changing culture/system was required

5 Key recommendations

• Standards - linked to measures of compliance

• Openness, transparency and candour

• Support for compassionate care

• Leadership - strong, patient-centred, regulated

• Information and data

Standards

• Measures of safety, care and outcome

• Determined by what public/patients want

• Agreed as deliverable by healthcare professionals

• Including publishing staffing levels

• Inspection as the main tool to assure compliance

Openness

• Enabling concerns to be raised freely without fear

• Transparency of accurate and useful data in public

domain

• Statutory duty of candour to inform patients when

avoidable harm has occurred

• Duty of candour for staff to report harm to managers and

not to be gagged

• Duty of providers to be honest with regulators

Compassionate care

• Nurse training must encompass compassion

• Professionalise healthcare assistants with

registration, regulated training and standards

• New registration of older people's nurse

• Strengthen voice of nursing

• Friends and family test

Leadership

• Enhanced and centralised leadership training for

NHS managers

• Code of conduct and ethics for managers

• Registration and regulation of managers

Information and data

• Healthcare information needs to be accurate,

comparable and timely

• Information systems need improvement

• Clinical audit has an important role in driving

improvement

Thoughts on improvement

Inspection and data

"Weighing a pig doesn't make it get fatter"

• Measurement alone does not improve care

• Better measurement does not make better care

• Measurement only improves care if it leads to

change

Thoughts on regulation

• Self regulation

• Professional

• Promotes open culture

• Encourages best practice

• External regulation

• Political

• Promotes closed culture

• Encourages defensiveness

Thoughts on regulation

• Necessary, but...

• Regulation may impede innovation

• Risks a race to the bottom / lowest acceptable

standard

• Measurable v meaningful

• System based on a fear of failure

Legal changes post-Francis

• New criminal offence for ill treatment or wilful neglect

• No requirement for 'harm' to have been suffered

• Organisations, as well as individuals, may be prosecuted if

activities are managed such that they cause a person to be

subject to ill treatment or neglect

• Sanctions include imprisonment, fine, disqualification from office

• Also it will be an offence to provide false or misleading information

(to regulators)

Is it really about mid-Staffs?

• Mid-Staffs was (we think) an extreme example

• It may just have been the first one to get caught in the

headlights

• Combination of persistent adverse data and public

pressure

• Serious systemic problems could happen anywhere

• In fact, they already have...

Alder Hey 1988-95

• Specialist children's hospital in Liverpool

• Parents of dead children discover that organs were

retained following autopsy without consent

• Public Inquiry

• Human Tissue Act 2004

• Human Tissue Authority set up

Bristol 1990-95

• High mortality rates following paediatric cardiac surgery

• Lack of monitoring and leadership

• Whistleblower Dr Steve Bolsin unable to work in UK

• Public Inquiry

• Led to publication of surgical outcomes

• Reconfiguration of paediatric cardiac surgery in England

recommended but still not happened

Colchester 2010-12

• "Inaccuracies" in cancer treatment waiting times

• Staff felt bullied or pressurised to change data

• Whistleblowers were ignored or told to "shut up"

• Internal investigations were inadequate

• Hiding poor practice seen (by staff) as preferable to

facing the board

• Consequence of a “fear of failure” culture

"How little can be done under the spirit of fear."

Florence Nightingale

2014

Post-Francis

• Helene Donnelly – now OBE

• Key whistleblower at Mid-Staffs

inquiry, raised over 100 concerns

• Now working as Ambassador for

Cultural Change for NHS Trust

• Advisor to Department of Health,

Royal College of Nursing and

Care Quality Commission

• Julie Bailey – now CBE

• Cure the NHS continues to raise

concerns about healthcare, not

just in Stafford

• Hounded by online abuse

• Forced to move away from

Stafford

March 2014

"Aborted babies incinerated to heat UK hospitals"

15,000 aborted or miscarried foetuses over 2 years

10 hospitals admitted to disposal as "clinical waste"

2 admitted to disposal in "waste-to-energy" plants

Daily Telegraph, 24 March 2014

“Human beings, who are almost unique in having

the ability to learn from the experience of others,

are also remarkable for their apparent

disinclination to do so.”

Douglas Adams, Last Chance to See

"Let whoever is in charge keep this simple question in

her head:

Not “how can I always do this right thing myself?”

but “how can I provide for this right thing to be always

done?"

Florence Nightingale

Over to you...

Postscript: Rules for whistleblowers

1.Consult your loved ones - will they support and love you whatever happens?

2.Test for support among colleagues, but don't assume this won't change

3.Try and use the internal systems and processes (but see 1. & 2.)

4.Don't embellish concerns, if anything play them down

5.Get legal or union advice (but see 1. & 2.)

6.Collect evidence (in your own time at your own expense, keep your own notes (see 1. & 2.)

7.Try and stay on good terms with colleagues but expect them to regard you as toxic (see 2.)

8.Network - does anyone share your concerns? (but see 2.)

9.Keep your own nose cleaner than clean (and beware 2.)

Finally, see 1. and good luck to you!

With thanks to Roy Lilley