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| Mid Staffs failures: who is to blame? | Mid Staffs failures: who is to blame? |
| (35 minutes later) | |
| Robert Francis QC stressed that his report did not conform to the tradition of blaming and sacking individuals or proposing yet another shake-up of the health service's organisational architecture. | Robert Francis QC stressed that his report did not conform to the tradition of blaming and sacking individuals or proposing yet another shake-up of the health service's organisational architecture. |
| "What has been found to be wrong here cannot be cured by finding scapegoats, and/or recommending major re-organisations yet again," Francis said. | "What has been found to be wrong here cannot be cured by finding scapegoats, and/or recommending major re-organisations yet again," Francis said. |
| Nevertheless, his report examined "what each organisation knew, or should have known which might have been expected to give cause for concern or further inquiry, and to what extent, if any, action as taken to address these concerns". | Nevertheless, his report examined "what each organisation knew, or should have known which might have been expected to give cause for concern or further inquiry, and to what extent, if any, action as taken to address these concerns". |
| It concluded that almost all the organisations within the NHS, both in and around the hospital and nationally, failed to some degree to appreciate the accumulating pile of evidence about care failings at Stafford hospital or do enough about it, or both. | It concluded that almost all the organisations within the NHS, both in and around the hospital and nationally, failed to some degree to appreciate the accumulating pile of evidence about care failings at Stafford hospital or do enough about it, or both. |
| This is a summary of his findings about key organisations involved. | This is a summary of his findings about key organisations involved. |
| Mid Staffordshire NHS Trust and its board | Mid Staffordshire NHS Trust and its board |
| While the wider NHS system did not act quickly enough on the warning signs emerging from Stafford hospital, "those with the most clear and close responsibility for ensuring that a safe and good standard care was provided to patients in Stafford, namely the board and other leaders within the trust, failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others". | While the wider NHS system did not act quickly enough on the warning signs emerging from Stafford hospital, "those with the most clear and close responsibility for ensuring that a safe and good standard care was provided to patients in Stafford, namely the board and other leaders within the trust, failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others". |
| Local GPs | |
| They only voiced concern about quality of care at the hospital after the Healthcare Commission, the NHS care watchdog at the time, announced it would investigate the trust. That was in 2008, three years after the poor care had begun. "The local medical community did not raise concerns until it was too late," said Francis. | They only voiced concern about quality of care at the hospital after the Healthcare Commission, the NHS care watchdog at the time, announced it would investigate the trust. That was in 2008, three years after the poor care had begun. "The local medical community did not raise concerns until it was too late," said Francis. |
| Local NHS primary care trusts | Local NHS primary care trusts |
| They "were under a duty to arrange for the provision of safe and effective care, [but] were not set up for and did not effectively ensure the quality of the health services they were buying". In mitigation, though, Francis also added that the various PCTs, which commission and pay for treatment, "did not have the tools to do the job properly". | They "were under a duty to arrange for the provision of safe and effective care, [but] were not set up for and did not effectively ensure the quality of the health services they were buying". In mitigation, though, Francis also added that the various PCTs, which commission and pay for treatment, "did not have the tools to do the job properly". |
| The strategic health authority | The strategic health authority |
| Francis said the SHA, the regional representative of the NHS and Department of Health (DH), "did not put patient safety and wellbeing at the forefront of its work. It defended trusts rather than holding them to account on behalf of patients. It was uncritical in its support of foundation trust status for the trust. It preferred to explain away concerns such as those about high mortality rates rather than root out matters which would concern any patient." | Francis said the SHA, the regional representative of the NHS and Department of Health (DH), "did not put patient safety and wellbeing at the forefront of its work. It defended trusts rather than holding them to account on behalf of patients. It was uncritical in its support of foundation trust status for the trust. It preferred to explain away concerns such as those about high mortality rates rather than root out matters which would concern any patient." |
| Francis also accused the SHA of forgetting that its core purpose was to help the NHS improve patient care; of offering "false reassurance" to the DH about the trust's fitness to become a foundation trust; not asking the Healthcare Commission if it thought the trust was a suitable candidate for that status; and doing too little to develop methods of monitoring safety standards. | Francis also accused the SHA of forgetting that its core purpose was to help the NHS improve patient care; of offering "false reassurance" to the DH about the trust's fitness to become a foundation trust; not asking the Healthcare Commission if it thought the trust was a suitable candidate for that status; and doing too little to develop methods of monitoring safety standards. |
| His report cites the SHA's evidence to the public inquiry that the trust "was but one of many organisations in the region with problems, and the SHA was relatively small and had a lot to cope with". But, Francis concluded: "This again is not an excuse for inaction. Either the SHA had the resources and ability to do the entire job which had been delegated to it, and it failed to carry out that job, or it did not have the resources and ability and failed to alert those responsible to the problem." | His report cites the SHA's evidence to the public inquiry that the trust "was but one of many organisations in the region with problems, and the SHA was relatively small and had a lot to cope with". But, Francis concluded: "This again is not an excuse for inaction. Either the SHA had the resources and ability to do the entire job which had been delegated to it, and it failed to carry out that job, or it did not have the resources and ability and failed to alert those responsible to the problem." |
| Monitor | Monitor |
| It played a key role in Mid Staffordshire's application to become a foundation trust (FT), semi-independent of Whitehall control. Its job then and now is to regulate the growing number of such trusts in the English NHS. | It played a key role in Mid Staffordshire's application to become a foundation trust (FT), semi-independent of Whitehall control. Its job then and now is to regulate the growing number of such trusts in the English NHS. |
| The watchdog was too quick to accept the trust's assurances that care at Stafford was good enough and should have "probed more deeply". It continued to believe there was too little evidence to suggest major problems at Stafford long after it should have recognised them, thanks to the Healthcare Commission's damning findings. | The watchdog was too quick to accept the trust's assurances that care at Stafford was good enough and should have "probed more deeply". It continued to believe there was too little evidence to suggest major problems at Stafford long after it should have recognised them, thanks to the Healthcare Commission's damning findings. |
| Monitor "focused on corporate governance and financial control without properly considering whether there were issues of patient safety and poor care". | Monitor "focused on corporate governance and financial control without properly considering whether there were issues of patient safety and poor care". |
| If Monitor and the commission had talked to each other and shared information, what Francis calls "the erroneous authorisation of the trust as an FT" would not have happened, he said. | If Monitor and the commission had talked to each other and shared information, what Francis calls "the erroneous authorisation of the trust as an FT" would not have happened, he said. |
| The failure of the "elaborate regulatory assessment process" – which would-be foundation trusts had to undergo – to bring failings at Stafford to light "calls into question the effectiveness of the FT regulatory system as a whole". | The failure of the "elaborate regulatory assessment process" – which would-be foundation trusts had to undergo – to bring failings at Stafford to light "calls into question the effectiveness of the FT regulatory system as a whole". |
| In a nutshell: "It was clearly not intended that a trust suffering from a systemic failure to provide such a service should be authorised as an autonomous entity, thus removing it from the secretary of state's sphere of accountability and control." | In a nutshell: "It was clearly not intended that a trust suffering from a systemic failure to provide such a service should be authorised as an autonomous entity, thus removing it from the secretary of state's sphere of accountability and control." |
| The Healthcare Commission | The Healthcare Commission |
| It is the only key NHS body to emerge with credit from Francis's dissection of the role played by a complex and interlinked plethora of organisations. It was its 2008-09 investigation that finally unearthed the appalling care at Stafford. While the seriousness of the inadequacy of care was so bad that independent performance management of the hospital was necessary, the NHS regulatory system at that time did not allow the commission to do that. | It is the only key NHS body to emerge with credit from Francis's dissection of the role played by a complex and interlinked plethora of organisations. It was its 2008-09 investigation that finally unearthed the appalling care at Stafford. While the seriousness of the inadequacy of care was so bad that independent performance management of the hospital was necessary, the NHS regulatory system at that time did not allow the commission to do that. |
| The commission was wound up in April 2009 by the Labour government as part of a money-saving streamlining of the regulation of health, social care and disability services. | The commission was wound up in April 2009 by the Labour government as part of a money-saving streamlining of the regulation of health, social care and disability services. |
| The Care Quality Commission | The Care Quality Commission |
| Francis reserved some of his strongest criticisms for the CQC, which replaced the Healthcare Commission in April 2009 as the watchdog of NHS care. | Francis reserved some of his strongest criticisms for the CQC, which replaced the Healthcare Commission in April 2009 as the watchdog of NHS care. |
| He highlighted the fact that, when it began, it had a huge job: of merging the roles performed by until then three separate regulators and scrutinising a wide range of care providers. But as criticism of it grew, it reacted with "a defensive institutional instinct to attack" its critics rather than embracing and learning from those criticisms. | He highlighted the fact that, when it began, it had a huge job: of merging the roles performed by until then three separate regulators and scrutinising a wide range of care providers. But as criticism of it grew, it reacted with "a defensive institutional instinct to attack" its critics rather than embracing and learning from those criticisms. |
| It has failed to adequately hold to account the NHS care providers it is meant to be scrutinising and suffers from "a lack of clarity" about what the regulatory requirements it is charged with enforcing are based on. "They are requirements which have to be met, but are not necessarily given very much attention as statutory obligations, in day-to-day clinical work," the report said. | It has failed to adequately hold to account the NHS care providers it is meant to be scrutinising and suffers from "a lack of clarity" about what the regulatory requirements it is charged with enforcing are based on. "They are requirements which have to be met, but are not necessarily given very much attention as statutory obligations, in day-to-day clinical work," the report said. |
| Francis acknowledged improvements in the CQC's approach but added that its "current outcomes are overly bureaucratic and fail to separate clearly what is absolutely essential from that which is merely desirable". | Francis acknowledged improvements in the CQC's approach but added that its "current outcomes are overly bureaucratic and fail to separate clearly what is absolutely essential from that which is merely desirable". |
| The watchdog was also criticised for giving too little priority to various forms of patient information and feedback when deciding which hospitals to investigate. | The watchdog was also criticised for giving too little priority to various forms of patient information and feedback when deciding which hospitals to investigate. |
| Despite Francis's remarks, the CQC will see its role expanded to become in effect a new super-regulator of the NHS, if ministers implement his recommendations. | Despite Francis's remarks, the CQC will see its role expanded to become in effect a new super-regulator of the NHS, if ministers implement his recommendations. |
| Its former chief executive Cynthia Bower – who also led the West Midlands SHA between 2006 and 2008 – resigned last year after persistent criticism of the CQC's capabilities. Its chair, Dame Jo Williams, followed late last year. Their replacements, David Behan and David Prior, plan to make the CQC a much more robust and interventionist regulator. | Its former chief executive Cynthia Bower – who also led the West Midlands SHA between 2006 and 2008 – resigned last year after persistent criticism of the CQC's capabilities. Its chair, Dame Jo Williams, followed late last year. Their replacements, David Behan and David Prior, plan to make the CQC a much more robust and interventionist regulator. |
| The Department of Health | The Department of Health |
| Unnamed officials "did not ensure that ministers were given the full picture when advising that the trust's application for foundation trust status should be supported. It was remote from the reality of the service at the front line," said Francis. | Unnamed officials "did not ensure that ministers were given the full picture when advising that the trust's application for foundation trust status should be supported. It was remote from the reality of the service at the front line," said Francis. |
| Crucially, in addition, "it is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current government." | Crucially, in addition, "it is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current government." |
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