On Tuesday 4th June the Academy for Healthcare Science (AHCS) held a workshop to discuss the implications of the Francis Report for Healthcare Scientists at Church House Westminster.
For anyone unaware, the Francis Report is the final report of the Francis Inquiry into failures of care at Mid Staffordshire NHS Foundation Trust which was published on Wednesday 6 February 2013 and has implications for the whole of the NHS.
The meeting started with coffee and a brief introduction from Keith Ison joint Chair of theHealthcare Science Board (HCSB) and John Stevens the Non-Executive Director of AHCS. The main aims of the day were to establish professional body response as a result of the Francis Report and to consider a collective response on behalf of all Healthcare Scientists.
It was at this point noted that although the report was supposed to include all NHS staff it was most certainly not Healthcare Science orientated.
Janet Monkman, AHCS Chief Executive, then gave a brief overview of the drivers for having the workshop, the main one being an agreed collaboration between the Healthcare Science Professional Board (HCSPB) Health Education England (HEE) and the AHCS to look at the implications of the Francis Report. The meeting hoped to gather the views, work and thoughts of stakeholders in order that a final paper could be submitted for consideration at HCSPB and AHCS Council.
John Stevens then took the floor to promote discussion about the report and also the Government Mandate published on 28th May which sets out plans to HEE for education and training for all NHS staff. The HEE has been set up to provide national leadership on education, training and workforce development and the mandate is a blueprint for NHS staff training. The only small problem is that is not particularly Healthcare Science orientated. The plan for healthcare Science would be to produce a draft paper with actions which could be shared with all healthcare scientists and the academy would then publish and promote this piece of work. There would be accountability for implementation of recommendations and an action plan which would be in the AHCS annual report.
John then took us on a quick run through the Francis report picking out the recommendations which could be seen as relevant to Healthcare Science as many of the 290 recommendations were aimed directly at medical or nursing staff. This was a theme that seemed to run through the day as many present commented that the patients rarely realised how many people were involved in their care as they only thought of those who they had direct contact with.
The recommendations which John had selected as being relevant were then each discussed.
Accountability for implementation of the recommendations
These recommendations require every single person serving patients to contribute to a safer, committed and compassionate and caring service.
Implementing the recommendations
The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires:
• A common set of core values and standards shared throughout the system;
• Leadership at all levels from ward to the top of the Department of Health, committed to and capable of
• involving all staff with those values and standards;
• A system which recognises and applies the values of transparency, honesty and candour;
• Freely available, useful, reliable and full information on attainment of the values and standards;
• A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system.
Putting the patient first
The patients must be the first priority in all of what the NHS does. Within available resources, they must receive effective services from caring, compassionate and committed staff, working within a common culture, and they must be protected from avoidable harm and any deprivation of their basic rights.
Clarity of values and principles
In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that:
• Staff put patients before themselves;
• They will do everything in their power to protect patients from avoidable harm;
• They will be honest and open with patients regardless of the consequences for themselves;
• Where they are unable to provide the assistance a patient needs, they will direct them where possible to those who can do so;
• They will apply the NHS values in all their work.
Fundamental standards of behaviour
Enshrined in the NHS Constitution should be the commitment to fundamental standards which need to be applied by all those who work and serve
in the healthcare system. Behaviour at all levels needs to be in accordance with at least these fundamental standards.
Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional disagreements about procedures must be required to take the necessary corrective action, working with their medical or nursing director or line manager within the trust, with external support where necessary. Professional bodies should work on devising evidence-based standard procedures for as many interventions and pathways as possible.
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.
A common culture made real throughout the system – an integrated hierarchy of standards of service
No provider should provide, and there must be zero tolerance of, any service that does not comply with fundamental standards of service.
Standards need to be formulated to promote the likelihood of the service being delivered safely and effectively, to be clear about what has to be done to comply, to be informed by an evidence base and to be effectively measurable.
The nature of standards
Standards should be divided into:
Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance;
Enhanced quality standards – such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to availability of resources;
Developmental standards which set out longer term goals for providers – these would focus on improvements
in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator.
All such standards would require regular review and modification.
Responsibility for, and effectiveness of, healthcare standards
Responsibility for regulating and monitoring compliance
The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations.
The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.
Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.
Need to share information between regulators
Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks.
It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.
Medical training and education
Training and training establishments as a source of safety information
Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the survey and routinely share information obtained with healthcare regulators.
Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.
Training visits should make an important contribution to the protection of patients:
• Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used.
• Visits to, and observation of, the actual training environment would enable visitors to detect poor practice from which both patients and trainees should be sheltered.
• The opportunity can be taken to share and disseminate good practice with trainers and management.
• Visits of this nature will encourage the transparency that is so vital to the preservation of minimum standards.
Openness, transparency and candour
Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.
Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.
Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.
Principles of openness, transparency and candour
Every healthcare organisation and everyone working for them must be honest, open and truthful in all their
dealings with patients and the public, and organisational and personal interests must never be allowed to
outweigh the duty to be honest, open and truthful.
181 Enforcement of the duty
Statutory duties of candour in relation to harm to patients
A statutory obligation should be imposed to observe a duty of candour:
On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may request;
On registered medical practitioners and registered nurses and other registered professionals who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare provider by which they are employed has caused death or serious injury to the patient to report their belief or suspicion to their employer as soon as is reasonably practicable.
The provision of information in compliance with this requirement should not of itself be evidence or an admission of any civil or criminal liability, but non-compliance with the statutory duty should entitle the patient to a remedy.
Strengthening identification of healthcare support workers and nurses
There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.
Registration of healthcare support workers
A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are dependent on such care by reason of disability and/or infirmity) in a hospital or care home setting. The system should apply to healthcare support workers, whether they are working for the NHS or independent healthcare providers, in the community, for agencies or as independent agents. (Exemptions should be made for persons caring for members of their own family or those with whom they have a genuine social relationship.)
Code of conduct for healthcare support workers
There should be a national code of conduct for healthcare support workers.
Training standards for healthcare support workers
There should be a common set of national standards for the education and training of healthcare support workers.
The code of conduct, education and training standards and requirements for registration for healthcare support
Workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other regulators, professional representative organisations and the public.
Professional regulation of fitness to practise
Nursing and Midwifery Council Investigation of systemic concerns
To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled to work closely with the systems regulators and to share their information and analyses on the working of systems in organisations in which nurses are active. It should not have to wait until a disaster has occurred to intervene with its fitness to practise procedures. Full access to the Care Quality Commission information in particular is vital.
The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising out of the same event or series of events but involving professionals regulated by more than one body. While it would require new regulations, consideration should be given to the possibility of moving towards a common independent tribunal to determine fitness to practise issues and sanctions across the healthcare professional field.
Enhancing the use, analysis and dissemination of healthcare information
It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.
As everyone considered the information we split into smaller groups to discuss the implications for each of our professional groups.
One of the main concerns was Registration and who best it could be promoted. The AHCS backs a move for the public to be made aware of the lack of registration within HCS which may lead to voluntary registration becoming mandatory where it is available.
“Role Creep” was also a concern, where multiple professions are taking on tasks that they have not been trained in. It was felt that especially in career framework 2-4 competencies need development.
Clear guidance and best practice in order to whistle blow effectively was also raised. Early intervention would improve situations. Empower junior levels of staff so they have a voice if there are any concerns and be able to spot the elephant in the room.
It was felt that Clinical Governance is a mandatory system which is failing to provide results and that until the need for change is accepted there will still be culture within the NHS which is not apparently putting the patient first, whether intentionally or not. Some of this is down to financial constraint and the impact of organisational change but the interface between professionals and the system does need improved. More attention paid to root cause analysis rather than quick fixes which don’t address the matter.
Residual concerns regarding anonymised open forum reporting for Professional Bodies were raised as well as concerns about differences between the private and public sector workforce. An effort to get the public to understand the issues is to be made by the Academy. Importantly clear ways of whistle blowing without fear and with clear guidance and support were seen to be important
Keith Ison agreed to take some of the issues forward and there would need to be liaisons with the School of Healthcare Science.
Janet agreed to write a draft paper for circulation and to seek views, identify actions and recommendations before sharing a final paper with Boards and Council.
This final paper will be published and promoted by the Academy.