Robert Francis workshop: Lessons from Mid Staffordshire

Yesterday I attended an excellent one-day workshop staged by the Health Quality & Safety Commission in partnership with Waitemata DHB. The guest of honour was distinguished British barrister Robert Francis QC, who has recently led the inquiry into the critical hospital failings at Mid Staffordshire in England, which resulted in shockingly bad standards of care being delivered over several years. It is likely that these failures contributed to the deaths of patients at the hospital, but beyond that, basic standards of care and compassion were sadly lacking at the hospital, and its managers and monitoring agencies failed to spot the serious problems.

Francis’ inquiry provided a public forum for many of the patients and their families whose dedication to raising their concerns despite bureaucratic obstruction meant that the Mid Staffordshire failings became an issue of national importance in the UK. The inquiry report examined the care delivered by the Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. It's a frankly enormous report – all 1700-odd pages of it – containing a whopping 290 recommendations to build a common NHS culture in which patient interests are put first, and in which openness and transparency become the norm throughout the system.

Francis was in New Zealand to share some of the lessons of Mid Staffordshire, and to prompt a debate about the likelihood of such events occurring here. For a detailed explanation of Francis’ findings and a summary of the Mid Staffordshire failures, the inquiry executive summary is a good starting point. Even that is 125 pages long, but it’s worth the effort.

Here are a few thoughts arising from Francis’ keynote address, delivered yesterday to a 200-strong audience at Rydges Hotel in Wellington, while an impressive spring storm raged outside, shaking the lampposts and scaring pedestrians trying to cross the Featherston Street intersection.

(These are my personal views, not those of my employer. Also, my interpretation of Mr Francis’ comments should not be taken as a ‘true and correct record’ of his views – I’m not a stenographer)

• The NHS’s culture of multiple reorganisations are well-documented, with seemingly endless turnover at the highest levels leading to transient leadership. Around 50 percent of NHS trust chief executives currently have been in their post for less than two years, which indicates a big turnover problem. In practice this means successful long-term working relationships and professional trust are harder to develop. The problem extends to political leadership too, with a revolving door in the health role at the ministerial level. 
• The Trust’s quest for the bauble of Foundation Trust status became the overwhelming focus of the board, to the detriment of other vital responsibilities, chief of which was patient safety.
• Financial success was always the board’s first priority. The board members failed to understand the safety concerns affecting their hospital and spent their time considering other matters.
• There were whistle-blowers at Mid Staffordshire, but their voices were ignored, treated as trouble-makers, or explained away as statistical anomalies. The board focused on financial performance instead, which was the criteria for Foundation Trust status.
• Whistle-blowers feared the consequences of revealing the problems they had identified. There was also a culture of bullying that stifled criticism and threatened concerned staff for raising their concerns.
• Personalities matter too. There were highly strained personal relationships in the department, which led to poor practice.
• There is also the concern that the NHS is a thoroughly hierarchical institution in which ‘people are waiting to be told what to do’, i.e. professional initiative is discouraged. 
• The overlapping regulatory systems in place were complex, poorly integrated and failed to cooperate. 
• Transparency is key. If more had been published earlier, it might not have taken a concerted patient campaign to bring the problems at Mid Staffordshire onto the national agenda. Lives may have been saved if problems had been identified earlier rather than swept under the carpet and ignored.
• Part of the problem at Mid Staffordshire was something as simple as the layout of the hospital. Hospital management and the chief executive were physically isolated from the day-to-day working of clinicians. Union representatives had also been physically isolated by relegating their offices to a prefab in the hospital carpark.

See also:

Blog: APAC 2013 forum, 1 October 2013

News: 'Stafford Hospital trust guilty over insulin death', 9 October 2013

News: 'Mid Staffs activist to leave home after "hate campaign"', 24 June 2013