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Mid Staffordshire scandal highlights NHS cultural crisis

2013; Elsevier BV; Volume: 381; Issue: 9866 Linguagem: Inglês

10.1016/s0140-6736(13)60264-0

1474-547X

Cyril Drouot, Isabelle Burnier, Alain Percivalle,

Healthcare Systems and Challenges

The final inquiry into the care scandal at Mid Staffordshire NHS Foundation Trust has revealed a profound crisis of culture at every level of the health service. David Holmes reports.It has taken more than 2 years of deliberation, evidence from more than 200 witnesses, and cost over £13 million, but last week the second Francis inquiry finally delivered its damning verdict on why, between 2005 and 2009, hundreds of patients may have died needlessly and countless more suffered appalling violations of their dignity at the Mid Staffordshire NHS Foundation Trust. The inquiry's conclusions, and its no fewer than 290 recommendations for change, now present the National Health Service (NHS) in England with what many regard as the greatest challenge in its history, at a time when it is already going through its largest ever reorganisation.Since its creation in 1946, the NHS has become an integral part of the UK's national identity. With that in mind, it's hard to overstate the level of incomprehension and incredulity from the public, politicians, and from within the NHS itself, at the sheer depth and breadth of the failings set out in the three volumes of Robert Francis QC's Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.The Mid Staffordshire Trust is made up of two hospitals barely 10 miles apart in the town of Stafford, just north of Birmingham in the West Midlands. Stafford Hospital is an acute hospital with what used to be a 24-hour accident and emergency department, while its sister, Cannock Chase Hospital, comprises a minor-injuries unit, rehabilitation facilities, and elderly care services. Between them the two sites share around 450 inpatient beds and about 3000 employees, serving a local population of around 320 000.The origins of the scandal there date back over a decade. As early as 2001, Francis reveals, the local Primary Care Group (groups which were the predecessors to Primary Care Trusts, and commissioned services from Trusts like Mid Staffordshire) expressed concerns about the management of the Trust. There was a lack of engagement and leadership of clinicians in the Trust, they said, and a report a year later highlighted a “‘mis-allocation of resources which could have been directed to specialties experiencing ‘enormous pressures’, a loss of ‘good consultants’”, and a lack of management support, inadequate equipment, poor theatre management, an over-reliance on agency staff, and the imposition of waiting list targets at short notice.Subsequent changes of management at the Trust did nothing to address those early concerns, and the problems mounted. The lid was finally lifted in 2009 when, having been spurred to investigate goings on at the Trust in 2008 by a combination of patients' complaints and abnormally high mortality figures first published in 2007, the now defunct Healthcare Commission (HCC) published a devastating report into the standards of acute care at the Trust. The first Francis inquiry was set up in the aftermath of the HCC report by the then Labour Secretary of State for Health Andy Burnham, primarily to give a voice to those who had been most affected and ensure that their experiences were “fully taken into account in the rebuilding of confidence in the Trust”.What the inquiry heard suggested “failure on a scale that cannot be adequately expressed in statistics”. The individual accounts of suffering are too numerous to list here, nor could they be done justice, but they spanned almost every aspect of care and painted an overall picture of a Trust devoid of humanity, totally incapable of recognising patients as people. “The shock that is the appropriate reaction to many of the experiences the Inquiry has been told about”, Francis concluded, “reflects the distance between the standard of basic care that is every patient's legitimate expectation and what has, on too many occasions, been delivered at Stafford Hospital.”Having laid bare in forensic detail the true extent of failings at the Trust, the narrow remit of the first inquiry left a number of important questions unanswered. Why, for example, were the plaintiff voices of patients and families unheeded for so long? Why were managers and clinical staff so tolerant of the appalling standards of care? And why, over the course of a decade, did so many warning signs go either undetected or ignored by the regional and national supervisory and regulatory apparatus? In 2010, Andrew Lansley, the Secretary of State for Health of the newly elected Coalition Government, appointed Francis to chair a second inquiry to provide answers to those questions.The answers are complex and they are many, says Francis, but at their heart is a profound crisis of culture at every level of the NHS. The inquiry found a deep rooted, pernicious cult of management, obsessed with achieving ill-conceived targets yet isolated and wilfully oblivious to day-to-day operational reality, and fixated on image management and cultivating positive publicity while demonstrating little or no interest in acknowledging or addressing problems. Throughout the period considered by the inquiry, from 2005 to 2008, the executive management of the Mid Staffordshire Trust was blinded to the appalling care given to patients at their hospitals by their excessive focus on securing Foundation Trust status. An oppressive atmosphere in which intimidation and bullying were rife prevented staff from raising concerns, and, when they did, swept them under the carpet.In parallel, the multiplicity of bodies with regulatory and oversight responsibilities in the NHS seemed to be asleep at the wheel. From health-care systems regulators and performance managers like Monitor, the Care Quality Commission, and the HCC, to professional bodies and regulators like the General Medical Council, the Royal College of Nursing, and the Nursing and Midwifery Council, “all such organisations have the responsibility to detect and redress deficiencies in local management and performance where these occur”, says Francis. “It does not need a public inquiry to recognise that this elaborate system failed dramatically in the case of Stafford. As a result, it is clear that not just the Trust's Board but the system as a whole failed in its most essential duty—to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital.” Not a single person has yet been held accountable for what happened at the Mid Staffordshire Trust. Yet the systemic failures that the case has brought to light suggest that although atypical, Mid Staffordshire is unlikely to be unique.The solution to such a cultural crisis, according to Francis, contained within the inquiry's 290 detailed recommendations for change, amounts to nothing short of a cultural revolution. Although dismissing any notion of further reorganisation or restructuring as unhelpful, Francis calls for a re-founding of the current system to re-emphasise “what is truly important” (panel). There should be a strong commitment to common values throughout the system; zero tolerance of noncompliance with fundamental standards of care; the NHS Constitution should be revised to ensure “transparency and candour in all the system's business”; strong leadership in nursing and other professional values; more support and training for those in leadership roles; true accountability; and accessible information to enable performance by individuals, services, and organisations to be compared. “By bringing all this together”, Francis writes, “all who work to provide patient care, from porters and cleaners to the Secretary of State, will be working effectively in partnership in a common and positive culture”.PanelThe cultural revolution (selected recommendations)New role for the NHS ConstitutionThe NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common values, as well as the respective rights, legitimate expectations, and obligations of patients.Regulatory reformTo close regulatory gaps, there should be a single regulator dealing with corporate governance, financial competence, viability, and compliance with patient safety and quality standards for all trusts. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow.The role of commissionersGeneral practitioners need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services.Openness, transparency, and candourA statutory obligation should be imposed on all health-care providers to observe a duty of candour. “Gagging clauses” or non-disparagement clauses should be prohibited in the policies and contracts of all health-care organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care.NursingThere should be an increased focus in nurse training, education, and professional development on the practical requirements of delivering compassionate care. Ward nurse managers should operate in a supervisory capacity, and not be office-bound. They should know about the care plans relating to every patient on his or her ward.In a sign of the enormity of the inquiry's conclusions, the Prime Minister David Cameron, rather than the current Health Secretary Jeremy Hunt, made a statement to Parliament, in which he accepted the inquiry's recommendations. How the recommendations can be implemented, at a time when the NHS is in the throws of its biggest restructure since its inception, is now the burning question.The London-based King's Fund charity has already done a lot of work on ways of translating some of the more abstract ideas promoted in the Francis inquiry around leadership and cultural change into practice, and Jocelyn Cornwell from the Fund sees the Francis inquiry as an important part of an ongoing debate. “I think it poses a more fundamental challenge not just to the NHS, but health care in modern industrial economies. You look in the [United] States and they have some different issues, but this business of people feeling like once they become a patient they then have to fit in with a system that doesn't really see them as people, that's not unique to the NHS”, she says. “Cultural challenge is a huge challenge.”The Fund currently works with 15 clinical teams across 11 acute trusts to help improve patient-centred and family-centred care, and has found that medical leadership is crucial to changing the culture of care. “We help teams examine the experience of their patients and set clear goals to improve them, and we've learnt some important lessons: one of which is the importance of medical leadership”, says Cornwell. “Doctors are still very powerful within the system, even though they might not always feel it, but they generally think in terms of clinical quality, and not in the round about the experience of their patients. In our teams where the consultants fully engage we see huge change happening very quickly.” For the NHS, that change can't come quickly enough. The final inquiry into the care scandal at Mid Staffordshire NHS Foundation Trust has revealed a profound crisis of culture at every level of the health service. David Holmes reports. It has taken more than 2 years of deliberation, evidence from more than 200 witnesses, and cost over £13 million, but last week the second Francis inquiry finally delivered its damning verdict on why, between 2005 and 2009, hundreds of patients may have died needlessly and countless more suffered appalling violations of their dignity at the Mid Staffordshire NHS Foundation Trust. The inquiry's conclusions, and its no fewer than 290 recommendations for change, now present the National Health Service (NHS) in England with what many regard as the greatest challenge in its history, at a time when it is already going through its largest ever reorganisation. Since its creation in 1946, the NHS has become an integral part of the UK's national identity. With that in mind, it's hard to overstate the level of incomprehension and incredulity from the public, politicians, and from within the NHS itself, at the sheer depth and breadth of the failings set out in the three volumes of Robert Francis QC's Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Mid Staffordshire Trust is made up of two hospitals barely 10 miles apart in the town of Stafford, just north of Birmingham in the West Midlands. Stafford Hospital is an acute hospital with what used to be a 24-hour accident and emergency department, while its sister, Cannock Chase Hospital, comprises a minor-injuries unit, rehabilitation facilities, and elderly care services. Between them the two sites share around 450 inpatient beds and about 3000 employees, serving a local population of around 320 000. The origins of the scandal there date back over a decade. As early as 2001, Francis reveals, the local Primary Care Group (groups which were the predecessors to Primary Care Trusts, and commissioned services from Trusts like Mid Staffordshire) expressed concerns about the management of the Trust. There was a lack of engagement and leadership of clinicians in the Trust, they said, and a report a year later highlighted a “‘mis-allocation of resources which could have been directed to specialties experiencing ‘enormous pressures’, a loss of ‘good consultants’”, and a lack of management support, inadequate equipment, poor theatre management, an over-reliance on agency staff, and the imposition of waiting list targets at short notice. Subsequent changes of management at the Trust did nothing to address those early concerns, and the problems mounted. The lid was finally lifted in 2009 when, having been spurred to investigate goings on at the Trust in 2008 by a combination of patients' complaints and abnormally high mortality figures first published in 2007, the now defunct Healthcare Commission (HCC) published a devastating report into the standards of acute care at the Trust. The first Francis inquiry was set up in the aftermath of the HCC report by the then Labour Secretary of State for Health Andy Burnham, primarily to give a voice to those who had been most affected and ensure that their experiences were “fully taken into account in the rebuilding of confidence in the Trust”. What the inquiry heard suggested “failure on a scale that cannot be adequately expressed in statistics”. The individual accounts of suffering are too numerous to list here, nor could they be done justice, but they spanned almost every aspect of care and painted an overall picture of a Trust devoid of humanity, totally incapable of recognising patients as people. “The shock that is the appropriate reaction to many of the experiences the Inquiry has been told about”, Francis concluded, “reflects the distance between the standard of basic care that is every patient's legitimate expectation and what has, on too many occasions, been delivered at Stafford Hospital.” Having laid bare in forensic detail the true extent of failings at the Trust, the narrow remit of the first inquiry left a number of important questions unanswered. Why, for example, were the plaintiff voices of patients and families unheeded for so long? Why were managers and clinical staff so tolerant of the appalling standards of care? And why, over the course of a decade, did so many warning signs go either undetected or ignored by the regional and national supervisory and regulatory apparatus? In 2010, Andrew Lansley, the Secretary of State for Health of the newly elected Coalition Government, appointed Francis to chair a second inquiry to provide answers to those questions. The answers are complex and they are many, says Francis, but at their heart is a profound crisis of culture at every level of the NHS. The inquiry found a deep rooted, pernicious cult of management, obsessed with achieving ill-conceived targets yet isolated and wilfully oblivious to day-to-day operational reality, and fixated on image management and cultivating positive publicity while demonstrating little or no interest in acknowledging or addressing problems. Throughout the period considered by the inquiry, from 2005 to 2008, the executive management of the Mid Staffordshire Trust was blinded to the appalling care given to patients at their hospitals by their excessive focus on securing Foundation Trust status. An oppressive atmosphere in which intimidation and bullying were rife prevented staff from raising concerns, and, when they did, swept them under the carpet. In parallel, the multiplicity of bodies with regulatory and oversight responsibilities in the NHS seemed to be asleep at the wheel. From health-care systems regulators and performance managers like Monitor, the Care Quality Commission, and the HCC, to professional bodies and regulators like the General Medical Council, the Royal College of Nursing, and the Nursing and Midwifery Council, “all such organisations have the responsibility to detect and redress deficiencies in local management and performance where these occur”, says Francis. “It does not need a public inquiry to recognise that this elaborate system failed dramatically in the case of Stafford. As a result, it is clear that not just the Trust's Board but the system as a whole failed in its most essential duty—to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital.” Not a single person has yet been held accountable for what happened at the Mid Staffordshire Trust. Yet the systemic failures that the case has brought to light suggest that although atypical, Mid Staffordshire is unlikely to be unique. The solution to such a cultural crisis, according to Francis, contained within the inquiry's 290 detailed recommendations for change, amounts to nothing short of a cultural revolution. Although dismissing any notion of further reorganisation or restructuring as unhelpful, Francis calls for a re-founding of the current system to re-emphasise “what is truly important” (panel). There should be a strong commitment to common values throughout the system; zero tolerance of noncompliance with fundamental standards of care; the NHS Constitution should be revised to ensure “transparency and candour in all the system's business”; strong leadership in nursing and other professional values; more support and training for those in leadership roles; true accountability; and accessible information to enable performance by individuals, services, and organisations to be compared. “By bringing all this together”, Francis writes, “all who work to provide patient care, from porters and cleaners to the Secretary of State, will be working effectively in partnership in a common and positive culture”. New role for the NHS ConstitutionThe NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common values, as well as the respective rights, legitimate expectations, and obligations of patients.Regulatory reformTo close regulatory gaps, there should be a single regulator dealing with corporate governance, financial competence, viability, and compliance with patient safety and quality standards for all trusts. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow.The role of commissionersGeneral practitioners need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services.Openness, transparency, and candourA statutory obligation should be imposed on all health-care providers to observe a duty of candour. “Gagging clauses” or non-disparagement clauses should be prohibited in the policies and contracts of all health-care organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care.NursingThere should be an increased focus in nurse training, education, and professional development on the practical requirements of delivering compassionate care. Ward nurse managers should operate in a supervisory capacity, and not be office-bound. They should know about the care plans relating to every patient on his or her ward. New role for the NHS Constitution The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common values, as well as the respective rights, legitimate expectations, and obligations of patients. Regulatory reform To close regulatory gaps, there should be a single regulator dealing with corporate governance, financial competence, viability, and compliance with patient safety and quality standards for all trusts. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow. The role of commissioners General practitioners need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. Openness, transparency, and candour A statutory obligation should be imposed on all health-care providers to observe a duty of candour. “Gagging clauses” or non-disparagement clauses should be prohibited in the policies and contracts of all health-care organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care. Nursing There should be an increased focus in nurse training, education, and professional development on the practical requirements of delivering compassionate care. Ward nurse managers should operate in a supervisory capacity, and not be office-bound. They should know about the care plans relating to every patient on his or her ward. In a sign of the enormity of the inquiry's conclusions, the Prime Minister David Cameron, rather than the current Health Secretary Jeremy Hunt, made a statement to Parliament, in which he accepted the inquiry's recommendations. How the recommendations can be implemented, at a time when the NHS is in the throws of its biggest restructure since its inception, is now the burning question. The London-based King's Fund charity has already done a lot of work on ways of translating some of the more abstract ideas promoted in the Francis inquiry around leadership and cultural change into practice, and Jocelyn Cornwell from the Fund sees the Francis inquiry as an important part of an ongoing debate. “I think it poses a more fundamental challenge not just to the NHS, but health care in modern industrial economies. You look in the [United] States and they have some different issues, but this business of people feeling like once they become a patient they then have to fit in with a system that doesn't really see them as people, that's not unique to the NHS”, she says. “Cultural challenge is a huge challenge.” The Fund currently works with 15 clinical teams across 11 acute trusts to help improve patient-centred and family-centred care, and has found that medical leadership is crucial to changing the culture of care. “We help teams examine the experience of their patients and set clear goals to improve them, and we've learnt some important lessons: one of which is the importance of medical leadership”, says Cornwell. “Doctors are still very powerful within the system, even though they might not always feel it, but they generally think in terms of clinical quality, and not in the round about the experience of their patients. In our teams where the consultants fully engage we see huge change happening very quickly.” For the NHS, that change can't come quickly enough.