While it hardly needed a fifth inquiry to expose the appalling lack of care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009, the accounts of neglected patients, lying in excrement, drinking from flower vases, have lost none of their power to shock. Nor indeed has the staggering figure of anywhere between 400 and 1,200 people dead who might otherwise have lived. But where the report from Robert Francis QC differed from its predecessors is in its focus, not on the details of what happened, but on the hows and the whys. It is scarcely less harrowing, even so.
What Mr Francis does not do is point the finger at particular individuals, despite vociferous campaigning for heads to roll – not least that of Sir David Nicholson, the NHS chief executive who was, in 2005, a regional official with oversight of Mid Staffs. Patients and their families may, understandably, feel short-changed; but Mr Francis is right. Not because individuals cannot be responsible and should not be held to be so; rather because the system needs more fundamental change.
A herd of management scapegoats risks creating the impression that the problem is thus swiftly solved. It is not. Mr Francis’s conclusions as to the endemic, cultural failings at the NHS trust – and way beyond it – make for far more disturbing reading than would an account of a few bad apples easily flicked from the barrel.
Instead, what the QC describes is a grotesque disconnect between those running the organisation and its purported purpose, with negligent, abusive and sometimes fatal results. The culture at Mid Staffs was one where the “corporate self-interest” of meeting targets and controlling costs took precedence over patients’ needs, where successes were proclaimed and failings ignored, and where poor standards were tolerated regardless of the consequences. The picture of a hospital with its priorities twisted so inhumanely out of shape is truly chilling.
Nor, sad to say, is this only a local problem. That the grave dysfunction at Mid Staffs was allowed to continue for an astonishing four years – in the face of persistent complaints by patients, their families, and even members of staff – only underlines the extent to which every level of the system is implicated, from the hospital, to the primary care trust, to the regulator, to the Department of Health. Amid so generalised a cultural malaise, there is no reason for confidence that Mid Staffs is an isolated case. The immediate review of care at hospitals with the highest mortality rates, announced by the Prime Minister, therefore comes not a moment too soon. And any number of regulators, patient groups and NHS staff bodies have sharp questions to answer as to why complaints were not more assiduously pursued.
Faced with such systemic problems, it is appropriate that Mr Francis’s near-300 recommendations range so widely. Many appear so elementary that it is hard to believe they are not already in place – the proposal that causing death or harm to a patient should be a criminal offence, for example, or the suggestion of formalised training for healthcare assistants. Equally, it is surely shocking that it takes the failures at Mid Staffs for NHS trust boards to be held accountable for the standards of care in their hospitals – as they will now be – as well as their financial performance.
Taken together, Mr Francis’s calls for a statutory “duty of candour” requiring NHS staff to be open about mistakes, for an established code of conduct the breach of which results in managers’ disqualification, and for a louder voice for nurses are long overdue. As is the creation of a beefed-up regulator, with Ofsted-style inspections focused explicitly on care standards, overseen by a Chief Inspector of Hospitals.
Most important of all, however, is the proposition that care and compassion become the priorities in the recruitment, training and ongoing assessment of medical staff and their auxiliaries. For all that the flawed system has much to answer for, it is too easy to blame the usual suspects of under-staffing, central targets and box-ticking alone. The unpalatable fact remains that in many cases the neglect described is of so basic a nature – the placing of food out of reach, or the failure to provide a drink of water – that even the broken organisation around them cannot entirely absolve individuals for their want of sympathy. Better management, different organisational priorities and closer monitoring can do much. But the change must also come from the heart.
David Cameron told Parliament that we “can only begin to imagine the suffering endured”. Quite so. The only possible redress is to ensure that Mid Staffs can never happen again. Mr Francis’s report is only the very beginning.