Published on February 17, 2014
The Francis Report: one year on The response of acute trusts in England Ruth Thorlby Judith Smith Sally Williams Mark Dayan 17 February 2014 © Nuffield Trust
What we did Explored the responses of acute hospital trusts in England to the Francis Report (February 2013) Aim: to understand the significance for hospitals of the Francis Inquiry findings, in the context of an evolving and complex environment – rising demand, finite resources, increasing regulatory scrutiny Result: provides a snapshot of the impact of the Francis Inquiry © Nuffield Trust
Rapid review of board papers from 37 trusts Electronic survey of chairs and chief executives at 158 acute trusts in England – 53 responses 48 in-depth interviews with staff at 5 case study sites (across three regions in England) Robert Francis QC – adviser to the project team © Nuffield Trust
What we didn’t do • Establish whether or not acute trusts acted on specific recommendations • Explore whether good intentions and reports of initiatives/actions had translated into change and improvement • Validate the perceptions of senior leaders in trusts with external bodies responsible for oversight of hospitals © Nuffield Trust
© Nuffield Trust
Survey suggests there is lots to be optimistic about… 82% reported taking 94% of boards new actions in reported having 93% reported that response to Francis assigned someone they already had – most commonly at board level to lead work underway on reviewing/increasing response to Francis many of the relevant nurse numbers, Report – most often recommendations improving complaints when the report was director of nursing, handling, and better but in fifth of trusts it published engagement with was the CE staff and patients © Nuffield Trust
Case study interviews suggest the Francis Report has added impetus to efforts to make quality of care the first priority… Initiatives to improve the range of data Recommendations Greater emphasis on listening to staff, about quality of care for improving organisational culture whistleblowing, and – particularly at ward through openness, clinical leadership, level and often in real transparency and time – and use of reviewing nurse candour have been peer reviews and staffing levels and well received skill mix mock ‘Keogh’ visits © Nuffield Trust
But profound tensions still exist… Quality vs finance: Senior leaders reported that the Francis report has reinforced efforts to prioritise quality of care as equal to, or ahead of, financial matters…..but ongoing tension between the two goals. E.g. meeting financial goals and ensuring safe staffing levels Standards measured most assertively/frequently vs internal quality activity: Some felt that the continuing desire of the central NHS management system to be assured that hospitals were meeting financial and other performance targets, could undermine work to improve and manage services more widely E.g. particularly an issue for 4hr A&E target © Nuffield Trust
A burdensome regulatory approach is reported… • Trusts reported greater pressure from external bodies seeking assurance of quality in the wake of the Francis report, including national regulators, NHS England’s local area teams and clinical commissioners • The collection and validation of data needed by external bodies was proving onerous for some hospitals • Leaders described a burdensome regulatory approach that seemed to be at odds with efforts to develop an open qualityfocused culture • Concerns were raised about insufficient coordination of monitoring and performance management of local trusts © Nuffield Trust
The culture of external performance management… • The culture of the external performance management and regulation system still felt punitive and overbearing at times • Some reported that the focus on financial balance still appeared to be uppermost in the minds of some commissioners and regulators • Some perceived that a shift in values of the wider system – to value what is happening to patients as the most fundamental principle – had not yet been demonstrated • A strong message from some interviewees was that efforts to bring about cultural change internally could be undermined by the performance management of acute trusts © Nuffield Trust
What some people told us… ‘What the NHS response to Francis utterly misses is that external inspection and assurance should not be relied upon, yet nationally most of the response de-powers boards and inflicts upon them, endless duplicative models of assurance.’ (Survey respondent) ‘I’ve never, in my whole career, felt more regulated.’ (Chief Executive, Case study trust) © Nuffield Trust
Challenges arising from Francis… Achieving Genuine Cultural Change …particularly in relation to staff feeling able to raise concerns without fear Ensuring The Correct Levels Of Qualified Nurses …in the context of financial constraints Managing The Tensions Between Quality And Finance …as financial pressures mount across the public sector Allowing Trusts Space To Develop And Learn From Locally Owned Quality Assurance Activity …and for national bodies (e.g. CQC, Monitor) to consider how these should relate to their own assessments of quality and safety © Nuffield Trust
Gaps highlighted by this research… The ‘health’ of the wider NHS system: trusts are being encouraged to use ‘cultural barometers’ to assess the health of their own organisations who is assessing the behaviour and functioning of the wider NHS system, to establish whether failings identified by the Francis report have been rectified? Leadership at health economy level: a leadership gap in the system was identified at the level of the local health economy who should take the lead at the level that matters most? © Nuffield Trust
What’s needed… Starter for ten: • Measuring the culture of the wider system • Tracking how far hospitals prioritise quality and safety • Publishing and benchmarking a suite of measures of patient experience/quality • Assessing staff engagement across and within trusts What are your thoughts on what else is needed? © Nuffield Trust
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