The “Francis Report”, the Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, is likely to have some implications for public involvement in the NHS. Here I review what the report is about and what it might mean for governors of foundation trusts and for Healthwatch.
The public enquiry concerned the conditions of appalling care that flourished in Mid Staffordshire General Hospital between 2005 and 2009, and that led to some 1,200 needless deaths together with needless suffering for many other patients and their families. But what happened in the hospital and in the NHS trust that managed it have been established by a previous enquiry. This latest (February 2013) report doesn’t go over that again, but instead looks beyond the hospital and the trust, at the involvement of other organisations.
The three reports that I feel are of greatest interest are as follows. It is essential to understand that these three reports have different purposes, so that reading just one of them does not show you the whole picture:
- The February 2010 report of the enquiry into what happened at the hospital, and into the performance of the NHS trust that managed the hospital: Independent Enquiry into Care Provided By Mid Staffordshire NHS Foundation Trust January 2005 – March 2009
- The December 2011 Counsel’s Submissions to the Public Enquiry. This summarizes the evidence in relation to other bodies that should have been monitoring the hospital but failed to do so effectively.
- The February 2013 Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, the latest report, which makes recommendations about how these other bodies should do things differently in future.
Because I want to focus on the roles of governors and Healthwatch, I’ll mainly review the latter two reports, which I’ll refer to as the Submissions and the Report for brevity. And in addition, I’ll refer to the Report’s Executive Summary as the Summary.
The Report is clearly written and easy to read. Don’t let anyone try to scare you off by saying it’s a legal document that only lawyers can understand. If you can understand this blog, you can understand the Report.
Here’s an example that makes an important point about governors of NHS Foundation Trusts (FTs) (para. 10.201 in Volume 2):
“The governors of an FT theoretically play an important role in its oversight. Their power to dismiss the chair and non-executive directors potentially gives them considerable scope to influence the running of the organisation. It is clear from the experience of the Trust’s governors, and from meetings the Inquiry had with governors at a number of other FTs of varying sizes that, in practice, there are numerous challenges facing them…”
The best approach to the Report is to read the Summary first, or the parts of it that interest you. At the end there’s a table of recommendations, and the last column in the table tells you which chapter in the main body of the Report has more information about each recommendation. So you can easily read more about the particular recommendations that interest you, without having to read all three volumes of the Report from cover to cover.
Beware, though, of only reading the recommendations. Some of them are not based on the events in Mid Staffordshire. They seem to have been inserted afterwards, sometimes without any real basis in evidence, presumably as a way of softening the impact of the report on some of the organisations that failed those 1,200-plus people in Staffordshire so badly.
The Submissions on the subject of governors concluded from the evidence that (Chapter 9, para. 602):
“The Trust’s Council of Governors had inadequate experience, training and information to play an effective role in holding the management of the Trust to account. Without a transformation in the way that Governors are selected and prepared for their tasks, it is unrealistic to expect them to act as an effective form of quality control. Their role in such a process must be clearly defined in future, and training and resources provided accordingly.”
To address inadequate experience, the Report makes no recommendation at all.
To address inadequate training, the Report recommends:
“Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust’s services.”
This ignores the fact that exposing and challenging deficiencies in the quality of the foundation trust’s services are no part of a governor’s formal role. Governors’ principal role relates to the performance of the trust’s board of directors, not to front-line services. It is training in that role in relation to the board that is needed, but the Report makes no recommendation about it.
To address inadequate information, the Report recommends (Rec. 36):
“A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible…”
Information in near real time is key to governors’ work, because they need to be able to take a view of what the board is doing, not what it did many months ago, so this part of the recommendation is sound. But a coordinated collection of accurate information about the performance of organisations already exists at the Health and Social Care Information Centre. The collection’s biggest problem (apart from delays in publication) is that the information in it is incomplete. Yet the Report does not recommend that the information should be complete, so in this respect the recommendation is weak.
The Report also makes several recommendations relating to information about compliance with standards, but standards are not the direct concern of governors. Governors’ direct concern is the performance of the trust’s board of directors, and it is the board of directors that should be concerned with standards.
To address transformation in the way that governors are selected, the Report makes no recommendation at all.
The Report makes several further recommendations concerning governors that do not address any of the findings of the enquiry. For example, it recommends (Rec. 48):
“The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.”
This appears to be based solely on the opinion of Amanda Sherlock, Director of Operations at the CQC, as she stated it in her evidence to the enquiry in May 2011. At that time the CQC had already drafted the letter, and it had already (in March) published its plans for working with governors. The “recommendation” is no more than a rubber-stamping of CQC’s proposals, which do not relate to the events in Mid Staffordshire.
The usefulness of CQC’s proposals is questionable. Public involvement in FTs was originally designed to work at two levels: governors having oversight of the board of directors, and LINk having oversight of front-line services. Drawing governors into LINk’s work draws them away from their role in relation to the board of directors, which is a challenging enough role as it is. Furthermore, it creates exactly the kind of overlap of functions that the enquiry’s findings elsewhere criticise (Summary, 1.126):
“In the case of Mid Staffordshire, the regulatory regime that allowed for overlap of functions led to a tendency for regulators to assume that the identification and resolution of non-compliance was the responsibility of someone else.”
Healthwatch will not come into being until April 2013. The Submissions refer to Healthwatch’s predecessor, LINk, which has an identical role in relation to NHS providers like foundation trusts. Both are local bodies.
The Submissions make several criticisms of Staffordshire LINk, referring to its unwieldy and unworkable structure, lack of guidance from the Department of Health, the fractiousness of LINk members, their disputes with the LINk’s host organization, lack of funding, and lack of integration with complaints advocacy services.
To address structure, the Report recommends (Rec. 145):
“There should be a consistent basic structure for Local Healthwatch throughout the country…”
This is in opposition to current government policy, which is to allow each local Healthwatch to decide for itself how it is structured. It will be interesting to see whether government policy on this changes between now and April, when Healthwatches will come into being.
The Report makes further detailed recommendations about Healthwatch structure, for example (para. 6.472 in Volume 1):
“…it would be appropriate to have a membership which includes local government elected representatives, representatives of local patient interest groups, healthcare professionals not directly employed by providers in the locality, and some members of the public selected by the group as a whole.”
If implemented, this could compromise Healthwatch’s independence. Local government is the provider of social care, and a local government representative at a high level within Healthwatch could steer Healthwatch away from failing social care services. Likewise, a clinician could steer Healthwatch away from failing services where colleagues might be implicated.
It’s disappointing that the Report’s findings do not support strongly independent local Healthwatches. In Mid Staffordshire, only the strongly independent group Cure the NHS succeeded in demanding a response to the appalling lack of care.
To address lack of funding, the Report recommends (Rec. 146):
“Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money.”
This sensible proposal has already been rejected by the Department of Health, on the grounds that local democratic accountability ensures every Healthwatch will have adequate funding, while ring-fencing would weaken local democratic accountability. It will be interesting to see whether Francis’ recommendation changes things.
Another potential problem with Healthwatch funding is that a local authority might pass over all the funding, but at the same time require its local Healthwatch to allocate some of the funding to additional functions, limiting the funding available for Healthwatch’s independent statutory role.
The Report’s findings and recommendations seem to have drifted away from events in Mid Staffordshire between 2005 and 2009, perhaps so as to appear more relevant in 2013. The result is that some of its recommendations have little to do with the original problem. Conversely some of the factors in the original problem are not addressed in the recommendations.
Governors in Mid Staffordshire at the time struggled to form an effective working relationship with the board of directors, but nothing in these recommendations helps present-day governors to do any better. Suggestions from Counsel to the Enquiry about selecting governors with experience went unheeded. On the contrary, suggestions from CQC about drawing governors away from their statutory role and into the work of LINk are promoted.
Staffordshire LINk’s key problem in relation to the failing hospital was that LINk members didn’t know what to look for in a failing hospital. Nothing in the recommendations helps Healthwatch to do any better. The Report only makes some recommendations about Healthwatch that are related to Staffordshire LINk’s internal problems, and even if those internal problems had not existed, LINk members still wouldn’t have known what to look for in a failing hospital.
Overall, Robert Francis seems to have become quite muddled by the range and volume of evidence given to the enquiry, failing in his Report to paint a coherent picture of what went wrong in all these organisations, and failing to come up with a coherent set of recommendations that tell us how matters can be improved.