What we have learned from the Francis Report

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What we have learned from the Francis Report

• Claire Barkley
• Medical Director SSSFT

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Overview

• Background- Francis I and II
• Comments on the report
• What does it mean for us?
• Focus on culture and leadership

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Sir Robert Francis QC
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Francis I

• The First Inquiry published February 2010
• Lack of basic care across a number of wards and
  departments
• Culture neither conducive to good care nor to
  staff support
• Low morale, lack of openness and acceptance of
  poor standards
• Management thinking dominated by financial
  pressures (and achieving FT status)

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Francis I (continued)

• Absence of clinical governance and lack of
  urgency in boards approach to problems
• Focus on systems rather than outcomes statistics
  and reports rather than patient experience data
• Lack of internal and external transparency
  regarding existing problems

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Francis II

• The second Inquiry published 6th February 2013
• Signals a need for significant culture change in
  NHS
• Examines roles of agencies involved with events
  at Mid Staffs during 2005-2009
• Conclusions are drawn from 300 witness statements
  and further consideration of first report
• 290 recommendations

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Recommended

• New statutory duties (candour)
• New criminal offences (deliberately misleading
  regulators)
• Every single person and organisation within the
  NHSneeds to reflect from today what needs to be
  done differently in the future

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• Responsibility to consider what is exposed by my
  two inquiries and to consider how to apply the
  lessons themselves, individually and collectively
• Organisations to report publically on regular
  basis on whether have accepted my recommendations
  and what they are doing to implement them
• House of commons select committee to review
  (progress) regularly

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Hospitals need more compassion, not cash

• Horror stories -1,200 deaths
• Inhumanity on a horrifying scale
• Devastating report
• Managers obsessed with Labours targets
• Patients ruthlessly neglected left lying for
  days in their own excrement or driven by
  desperate thirst to drink rank water from flower
  vases
• Many were sent home with life-threatening
  illnesses
• Culture of bullying and neglect spread from top
  to bottom
• Anguished complaints of relatives were simply
  ignored
• Daily Mail Comment 7 February

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5 main recommendations

• Clearly understood fundamental standards and
  measures of compliance
• Openness, transparency and candour throughout the
  system
• Improved support for compassionate and committed
  nursing
• Strong and patient centred healthcare leadership
• Accurate, useful and relevant information

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Commentators

• What was said in
• Health Service Journal (HSJ)?

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Those in favour..

• Genie out of bottle in terms of principles and
  values being more important in how we manage NHS
• You could summarise the whole document in one
  sentence-we have lost the focus on caring
• It is a reference point for what is going wrong
  and should not happen again
• Taps into what people are thinking
• Has identified a problem which must be addressed

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Criticisms

• Good stuff tends to be very woolly and motherhood
  and apple pie
• If you are trying to change the culture, putting
  the fear of God into everyone is not necessarily
  the way
• It is like seeing the right label on the door and
  when you open the door there is nothing there
• He relies too much on the NHS Constitution. The
  vast majority dont know it exists
• I dont see Francis as an inflection point

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Government response

• 5 (different) themes
• Prevention of problems
• Detection of problems at early stage
• Taking action promptly to remedy problems
• Robust accountability
• Staff training

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What have commentators said?

• Endorses main message that listening to and
  understanding patients must come first
• Focus on 5 areas
• Vulnerable elderly care standards
• Development by CQC with patients, staff and other
  stakeholders
• NHS Constitution
• Clarification of regulatory arrangements
• Enhance use of real time data on quality
• Nuffield trust (19th March)

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HSJ Expert Panel

• HSJ gathered panel of 15 experts 13 March 2013
• Half said poor care likely to remain at same
  level and half said likely to get worse
• Pointed to role of organisational changes and
  tensions in causing worsening of situation
• Impact of removal of 4 of tariff year on year
• Nursing burnout second only to recession-hit
  Greece

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HSJ (cont.)

• Incentivised the wrong things- nurses encouraged
  to move away from bedside
• Political reform, reluctant workforce, top-down
  fixing, enforcement, perfect storm for more
  disasters in health care system
• What happens to staff in health care system?
• Start out motivated and optimistic
• Something our system does to staff
• Raising concerns, challenging poor practice

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• Eyes and ears of the service
• More people working on financial probity that
  clinical quality?
• Different culture in US-senior staff looking at
  quality data weekly
• Costs to individual of whistle-blowing
• Tradition in NHS of saying what people want to
  hear

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• Glitterisation of NHS-celebrating brilliant stuff
  and in denial about bad stuff
• Suggestion of HSJ whistleblower of the year
  award- Golden Whistle
• (Phil Hammond)

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• Reasons we do not address poor care
• Never a secret
• Worry about reputational damage prevents us
  responding to concerns in open manner

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Nuffield Trust

• Focus on development of standards of care for
  vulnerable elderly
• Lead role to CQC
• Promotion of NHS Constitution in staff
  recruitment, induction and appraisal
• Clarification of regulatory arrangements
• Enhanced real time data collection to measure
  quality of care

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• What does all this mean?

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Francis Frenzy

• Risk of fragmenting the report and designing
  action plans without seeing the whole context
• Hitting targets and missing the point
• We feel uncomfortableeasier to act than reflect
  on what happened
• Were those people different from us?
• How could they have overseen patient care which
  so obviously fell short and amounted in some
  cases to cruelty and neglect?

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Why did they do it?

• Were staff conforming to an unspoken code of
  conduct or rule?
• Had process taken over?
• Not seeing the impact of their actions?
• Or ignoring it?
• Depersonalising care
• Dehumanising patients

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Perhaps

• We do what is expected and if others appear
  comfortable it is hard to resist
• If we do not see the direct impact we can be less
  sensitive (managers?)
• Good people do bad things..
• Surely there are other places where this occurs

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• Given the right setting conditions, people behave
  in ways they would otherwise consider harmful
• Social pressure and conformity
• We know morale is low (doctors worldwide
  according to Edwards and Kornacki 2002)
• Need for a new compact?

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Isabel Menzies Lyth
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Menzies Lyth, Isabel (1959)

• 'The Functions of Social Systems as a Defence
  Against Anxiety A Report on a Study of the
  Nursing Service of a General Hospital', Human
  Relations 13 95-121 reprinted in Containing
  Anxiety in Institutions Selected Essays, vol. 1.
  Free Association Books, 1988, pp. 43-88

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Isabel Menzies Lyth

• Need to take a wide view of an institution in
  assessing its effectiveness in carrying out its
  primary task.
• Would include
• the whole way the institution functions
• its management structure, including its division
  into sub-systems and how these relate to each
  other
• the nature of authority and how it operates,
• how it manages anxiety
• social defence systems built into the institution
• its culture and traditions

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What is meant by Culture?

• A pattern of shared basic assumptions- invented,
  discovered or developed by a given group as it
  learns to cope with its problems of external
  adaptation and internal integration-that has
  worked well enough to be considered valid and
  therefore to be taught to new members as the
  correct way to perceive, think and feel in
  relation to those problems
• (Schein, 1985)

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Emphasis on Culture

• A fundamental culture change is needed
• Francis approach to culture criticised as being
  aspirational and too broad brush
• However research into culture, its nature and how
  it is changed shows it can be shaped and this can
  produce benefits, but this is a nuanced area and
  more complex than portrayed by Francis

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• Davies and Mannion argue that a common culture as
  recommended by Francis may be neither possible
  nor even desirable
• (BMJ 23/03/13)
• Organisational culture
• Values
• Beliefs
• Assumptions
• Ways of thinking that are translated into common
  and repeated patterns of behaviour

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• Maintained and reinforced by the rituals,
  ceremonies and rewards of everyday organisational
  life
• The way we do things round here
• Plus the shared ways of thinking which underpin
  these norms
• Culture in large organisations rarely uniform

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The cultural paradigm

• Stories
• Symbols
• Routines and rituals
• Controls
• Organisational structures
• Power
• Johnson and Scholes

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NHS Staff

• United only by 2 main issues
• The need for care to be based on individual need
  rather than funding
• Dislike of constant interference into healthcare
  provision by successive UK Governments
• Morgan and Ogbonna

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Culture

• Simply urging people to think differently is
  unlikely to over-ride the complex personal and
  social forces that shape organisational behaviour

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Culture eats strategy for breakfast
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Health care cultures

• Multiple, competing subcultures, some focussed on
  professional groups
• Linked to teams, wards, services, hospitals
• Differences in power
• Struggles for legitimacy
• Striving for cultural uniformity may be over
  optimistic

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• Ambulance crews, support structures, emotional
  burden of caring
• Prof John Glasby
• Attempts at cultural manipulation and performance
  management might have unintended dysfunctional
  consequences
• Perhaps better to concentrate on the individuals
  responsibility to make appropriate choices and
  act professionally
• There is not a single set of prescriptions to
  apply to each group as different pressures apply

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Culture formation

• Group
• History of shared experience
• Shared learning
• Stability of membership
• Human need for stability, consistency and meaning
• Culture
• The Kings Fund

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3 problems relating to culture

• Socialisation- teaching newcomers
• Behaviour- cultural predispositions and
  situational contingencies
• Subculture
• Normal- relate to different experiences and
  assumptions
• Often in conflict e.g. managerial and
  professional
• Common assumptions in a crisis

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Culture follows the leader

• Cannot consider culture apart from leadership -
  need to look at both
• Leaders need to be conscious of culture
• New groups and organisations create new cultures
• Once cultures exist the leaders influence the
  leadership criteria- who will and will not lead
• To influence culture you need to be a learning
  leader

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Trusts most capable of buffering shocks had

• Stable leadership
• Participative cultures with strong engagement
• Emphasis on organisational learning
• McKee, West et al 2010

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Research shows leaders actions speak louder than
formal communication

• The argument for changing my behaviour-
• Leadership 65
• Communications 10
• Systems and processes 25
• Grapevine ?
• Schein

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Solutions?

• Assess national initiatives before implementation
• Support whistleblowers and enable support for
  those who raise concerns
• Qualitative and quantitative data
• Advocates, leaders
• Openness
• Develop our own leadership skills

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RCPsych

• Passing on concerns
• Medical leadership
• Independent regulator

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Leadership is key
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Francis Report Leadership

•   214 Shared training
• A leadership staff college or training system,
  whether centralised or regional, should be
  created to provide common professional training
  in management and leadership to potential senior
  staff promote healthcare leadership and
  management as a profession administer an
  accreditation scheme to enhance eligibility for
  consideration for such roles promote and
  research best leadership practice in healthcare

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• 215 Shared code of ethics
• A common code of ethics, standards and conduct
  for senior board-level healthcare leaders and
  managers should be produced and steps taken to
  oblige all such staff to comply with the code and
  their employers to enforce it.
• 216 Leadership framework
• The leadership framework should be improved by
  increasing the emphasis given to patient safety
  in the thinking of all in the health service.
  This could be done by, for example, creating a
  separate domain for managing safety, or by
  defining the service to be delivered as a safe
  and effective service.

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• 217 Common selection criteria
• A list should be drawn up of all the qualities
  generally considered necessary for a good and
  effective leader. This in turn could inform a
  list of competences a leader would be expected to
  have.
• 218 Enforcement of standards and accountability
• Serious non-compliance with the code, and in
  particular, non-compliance leading to actual or
  potential harm to patients, should render
  board-level leaders and managers liable to be
  found not to be fit and proper persons to hold
  such positions by a fair and proportionate
  procedure, with the effect of disqualifying them
  from holding such positions in future.

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• 219 A regulator as an alternative
• An alternative option to enforcing compliance
  with a management code of conduct, with the risk
  of disqualification, would be to set up an
  independent professional regulator. The need for
  this would be greater if it were thought
  appropriate to extend a regulatory requirement to
  a wider range of managers and leaders. The
  proportionality of such a step could be better
  assessed after reviewing the experience of a
  licensing provision for directors.

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• 220 Accreditation
• A training facility could provide the route
  through which an accreditation scheme could be
  organised. Although this might be a voluntary
  scheme, at least initially, the objective should
  be to require all leadership posts to be filled
  by persons who experience some shared training
  and obtain the relevant accreditation, enhancing
  the spread of the common culture and providing
  the basis for a regulatory regime.

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• 221 Ensuring common standards of competence and
  compliance
• Consideration should be given to ensuring that
  there is regulatory oversight of the competence
  and compliance with appropriate standards by the
  boards of health service bodies which are not
  foundation trusts, of equivalent rigour to that
  applied to foundation trusts.

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Francis report what went wrong with NHS
leadership?

• Why were the leaders apparently unable to see or
  hear feedback from the frontline?
• Culture of fear
• Compare with other safety cultures e.g. aviation
• Lack of focus on psychological safety
• Dympna Cunnane and Robert Warwick
• Guardian Professional 14/02/13

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• Impact of Griffiths 1980s
• Managerial mindsets
• Danger of centralised processes in service
  related industries (Cassoni from JLPartnership)
• Tension between giving excellent service and
  standardisation of processes

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• The hollow centre
• Meaning and purpose has given way to process
• Need to design organisations with core purpose in
  mind
• Mindful leaders required who can bridge the gap

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Towards a culture of safety

• Tension exists between
• Creation of an efficient reliable organisation
  and
• Fostering adaptable, appropriate and
  compassionate care
• Not either/or but BOTH required
• If this breaks down the result is harm
• 21st century leadership task is to get the best
  out of all concerned, to enable them to be
  greater together

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• New models of leadership required
• Distributed leadership
• Interdisciplinary working
• Patient centred
• Managers and clinicians together
• All voices heard

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• Staff and service user views important but not
  sufficient
• Ethical considerations where a tension exists
• Balancing with pressures, anxieties, emotion and
  challenge of caring for people with many needs
• Reflective practice and peer review
• Holding ourselves and others to account
• Respectful challenge

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Summary of the task ahead

• Creation of a consistent, caring culture
• Vignettes at interviews?
• Being effective, reflective and subject to peer
  review
• Rewarding the behaviours we wish to encourage
• Role modelling
• A learning culture

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Our teams

• Ask if any of these conditions (active failures)
  exist in our teams (mosquito)
• Latent conditions (swamps) which lie dormant
  until active failure triggers them
• Emotional support for staff
• Glasby

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Staff support

• Don't nurture people,nurture their primary task
  - then you nurture people.E Menzies Lyth

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Thanks for your attention

• Claire.barkley_at_nhs.net