Use and abuse, coming to a government run health care system near you.............
Mid Staffs report calls for sweeping changes to improve patient safety
Report into scandal makes 290 recommendations to ensure patients' interests become top priority for NHS
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| Up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital. Photograph: Christopher Furlong/Getty |
The report by Robert Francis QC, who chaired the 31-month public inquiry into the scandal, amounted to a damning indictment of NHS attitudes, practices and organisations.
Francis made no fewer than 290 recommendations, which he said were designed to ensure that patients' interests became the top priority for the NHS and that in future any lapses in care standards are detected and stopped right away, unlike at Stafford hospital.
Ministers will have to contemplate further changes to the NHS's system of regulation – which Francis has found to be seriously wanting – and monitoring of hospitals.
David Cameron, apologising on behalf of the government and country for the way the system had allowed "horrific abuse to go unchecked and unchallenged" for so long, said the report's evidence of systemic failure means "we cannot say with confidence that failings of care are limited to one hospital".
He confirmed a new post of chief inspector of hospitals would be created from the autumn and demanded that the General Medical Council and Nursing and Midwifery Council, the professional bodies policing doctors and nurses, explain why no one had been struck off for their part in the failings. He also said the Health and Safety Executive must say why there had been no prosecution.
An estimated 400-1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital in one of the biggest NHS scandals.
As the report was published, Francis delivered an excoriating verdict on conditions at Stafford and demanded a change of culture to put patients first from the top to bottom of the NHS, which, he said, had "betrayed the public".
He said: "This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.
"We need a patient-centred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership, caring compassionate nursing, and useful and accurate information about services."
Francis said that while the hospital trust itself bore most of the responsibility for allowing "appalling suffering of many patients" to go unchecked between 2005 and 2009, multiple failures by a wide array of organisations and individuals across "the NHS system" allowed poor care to persist and meant opportunities to intervene were not taken.
Patients were left at risk at the hospital even after the then NHS regulator sounded the alarm about unusually high death rates there, he added. Checks and balances designed to protect patients did not prevent "serious systemic failure of this sort".
In a scathing assessment of the trust's board of directors, Francis accused it of "a serious failure" of its duties. "It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the trust's attention. [It also] failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from management and leadership responsibilities," he said.
But he also cited the hospital A&E unit's need to treat 98% of patients arriving there within four hours to meet the government's key NHS targets, the trust's attempts to balance its books and its "seeking foundation trust status … at the cost of delivering acceptable standards of care" as contributory factors.
Francis said in future the NHS should have a relentless focus on fundamental standards of care which, if breached should lead to serious sanctions.
"Any service or part of a service that does not consistently fulfil the relevant fundamental standards should not be permitted to continue," Francis said, in a move that could lead to the closure of hospital units arousing concern.
In addition, "non-compliance with a fundamental standard leading to death or serious harm of a patient should be capable of being prosecuted as a criminal offence, unless the provider or individual concerned can show that it as not reasonably practical to avoid this", he recommended.
Francis also recommended the creation of, in effect, one new super-regulator for the NHS to scrutinise both clinical and financial standards. Those tasks are currently performed separately by two watchdogs – the Care Quality Commission (CQC), which regulates care, and Monitor, which regulates semi-independent foundation trust hospitals and is due to become the NHS in England's overall financial regulator in April.
In a letter to the health secretary, Jeremy Hunt, accompanying his report, Francis said the causes of the NHS's failings at Mid Staffs included:
• A culture focused on doing the system's business – not that of patients
• Too great a degree of tolerance of poor standards and of risk to patients
• An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern
• A failure of communication between the many agencies to share their knowledge of concerns.
Action against Medical Accidents welcomed the recommendation to make it a statutory duty for NHS staff to own up to their mistakes, for which it has been campaigning strongly.
Its chief executive, Peter Walsh, said ministers must accept the recommendation, "which would represent the biggest advance in patient safety and patients' rights in the history of the NHS", he said.
Walsh added: "So far they have fiercely resisted this. The duty of candour, together with other recommendations to ensure full openness and transparency, represent a new dawn for the NHS. Organisations that sweep errors under the carpet do not learn lessons. An open and transparent NHS will be a safer NHS."
Clare Gerada of the Royal College of GPs said: "At a time when the NHS is under greater than ever financial pressure, it is imperative that the needs of patients are put first, and that cuts are not made which could jeopardise the safety of patient care."
Cathy Warwick of the Royal College of Midwives also welcomed the duty of candour suggestion. "We hear far too often from midwives who are genuinely petrified about raising the alarm bell over poor quality of care," she said. "They fear that senior managers will come down on them hard simply for raising concerns … NHS staff must never again be afraid to raise concerns about standards of NHS care. Today must be a watershed for the NHS."
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