What is going wrong in this country? There’s food for thought in the Francis Report into the litany of neglect at Mid Staffordshire Foundation Trust…
Maidstone. Tunbridge Wells. Stoke Mandeville. Mid Staffordshire. Basildon and Thurrock. All NHS hospitals where, in recent times, there was clear evidence of poor care and in some instances a high mortality rate. A superficial reading of these situations would be to say that this is what happens when a service is understaffed.
But while a staff shortage is a feature of these situations, it is not the explanation of what went so wrong. It would also excuse the collective refusal of responsibility by workers to take charge and in so doing, protect the patient. That is not to condemn individual workers who tried their best in those difficult environments, but workers need to remember the limitation of doing your individual best.
Some situations need a collective and organised response – “organised” in the sense that workers use their collective power to change the situation. At one time it was popular to point to the NHS as a bit of “socialism” in our country. But there is no socialism where groups of workers know there are bad things happening but decide to ignore them and blatantly refuse to take responsibility or to deal with it via the collective power of trade unions or professional groupings, which could have made the difference.
Now we have a very detailed report on the situation at Mid Staffordshire NHS Foundation Trust, which should be compulsory reading for NHS staff, other public service workers and indeed any worker who sits and wonders “What is going wrong in this country?”
Purpose of the inquiry
Concerns about mortality and the standard of care provided at Mid Staffordshire NHS Foundation Trust have been in the news for over a year following the publication in March 2009 of an investigation by the Healthcare commission. But the Francis Report, published in February 2010, was asked “to give those most affected an opportunity to tell their stories” and to ensure that lessons were learnt.
The terms of reference also allowed the inquiry “to gather the views and experience of the staff at the Trust and to seek explanations from management, including the directors, for what happened”.
The terms of reference meant that 966 individual members of the public contacted the inquiry. Most of those expressed concerns about the care received but a substantial minority only had positive comments to make, showing that in the midst of this horror, individual workers were able to continue to provide an adequate service for some.
Robert Francis, a lawyer, was so shocked by the evidence that came forward that he has presented all the written testimony from patients and relatives as Volume 2 of his report. All the testimonies are presented in chronological order from 2005 to 2009, including those which describe positive experiences. However most of the testimony is terrible to read.
The evidence gathered by the Inquiry shows clearly that for many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid.
Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding.
Staff failed to make basic observations, and pain relief was provided late or in some cases not at all. Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards.
The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.
The executive summary of the report notes that the experience of listening to so many accounts of bad care, denials of dignity and unnecessary suffering was of a “different order” to that of just reading the accounts. But the reading is shocking enough.
As you read those accounts remind yourself that they extend over a four-year period and that during that time the hospital rated itself as “good” in a self evaluation exercise. And it was awarded “Foundation” status by the government. And it was a training hospital for medical and nursing students.
Recommendation 4 is that “The Trust, in conjunction with the Royal Colleges, the Deanery and the nursing school at Staffordshire University, should review its training programme for all staff to ensure that high-quality professional training and development is provided at all levels.” And maybe at the same time they should ask why their systems of educational review failed to highlight concerns sooner.
The inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care. In particular it found that the ratio of registered nurses to health care support workers was inappropriate, with too few registered nurses to safely nurse highly dependent patients and to safely delegate to support workers.
Problems at the Trust were exacerbated at the end of 2006/07 when it was required to save £10 million from its budget. The Board decided it could only achieve this saving through cutting staffing levels, which were already insufficient. The evidence highlighted the Board's focus on financial savings as a factor leading it to reconfigure its wards in an essentially experimental and untested scheme, while continuing to ignore the concerns of staff.
When the Mid Staffordshire story first became national news, a frequently asked question was why did staff not speak out. The inquiry has shown that a number of staff did speak out and concluded:
“It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out."
What emerged from the report was a series of individuals who tried to blow the whistle and, in a way, an illustration of why this individualistic process does not change anything.
But it wasn’t only individuals who raised concerns. In one instance a group of nurses from a ward wrote a letter to the manager detailing the “intolerable conditions”. It concluded by saying they no longer felt that they “ran the ward.” This letter was sent anonymously from the “ward nurses”. They had been encouraged to do so by a medical consultant. The hospital managers who received that letter ignored it. So three elements of the workforce, who could have made a difference if they had stood together, formed part of an ineffectual chain.
What about the trade unions?
Peter Carter, General Secretary of the Royal College of Nursing, attended the inquiry to describe a visit he had made to the hospital and the unsatisfactory circumstances he had witnessed on that visit.
But there was no witness to the inquiry on behalf of the local branch and no evidence that the General Secretary’s visit had led to any change. It was left to a Director of Human Resources to tell the inquiry that when she arrived at the Trust the trade unions had not sat down with management to negotiate over polices and jobs, and “there had been no Agenda for Change panels run here for over a year”. So the day-to-day workings of the trade unions at the hospital had been utterly neglected.
What about professionalism?
Phrases like “professional standard” are clearly understood, and instances when individuals fail to meet a professional standard can be identified, but the processes for ensuring professional standards demand a collective commitment and vigilance. Neither featured in this situation.
Instead two frequently used excuses, which will be familiar to workers up and down the land, were much utilised at the hospital. First, the “I will just get my head down and do my job to the best of my ability” and then the “when it gets really bad something will change” approach.
In the case of the medical consultants at the hospital (and remember the outcome of the neglect was unnecessary death) the picture that emerges is one of disengagement and contempt for how the hospital was managed. They thought they could just get down and “do their job” and ignore what was happening to the hospital organisation.
Consultants failed to attend crucial meetings which looked at the way the hospital was run – indeed the consultant chairing the meeting told the inquiry that he occasionally put “car parking” as an item on the agenda even when there was no issue under that heading, as this meant slightly more people turned up.
The futility of waiting until things get “really bad” is evidenced by virtually every page of the report. The accident and emergency department was referred to by staff as “Beirut”; and staff are described as developing an “immunity” to patients being in pain because poor pain management became endemic. On the Emergency Admissions Unit staff described the working conditions as “intolerable” and openly discussed how working there could threaten their registration.
The managers and the board lost contact with the everyday reality and rarely visited the departments unless to accompany a visitor. They focused on targets, summarised by the inquiry as “a focus on process at the expense of outcomes” (again remind yourself that those “outcomes” were death).
The inquiry also details extensive bullying of front-line staff for failing to meet those targets and clear evidence from staff of pressure to falsify documentation to make it appear that patients had been less than 4 hours in the accident and emergency department. As the trade union response to that bullying was lacking, the failure of trade unionism and the failure of professionalism combined, contributing to the catastrophic outcome.
Some of the managers and staff who reported to the inquiry continued to maintain a “head down” approach and, as the inquiry chairman said, “rather than reflecting on their role and responsibility” wanted to minimise the significance of the findings.
After all the terrible experiences one might have expected the many relatives and visitors who attended the inquiry to have wanted the hospital to close. Not so: they wanted to see actions and improvement. But the first recommendation of the inquiry is that the trust needs to focus on providing high quality of care and “It should not provide a service in areas where it cannot achieve such a standard”.
The onus is now on the staff to take heed of that advice. The inquiry described an endemic culture of neglect and fearful staff afraid to take action. Changing the culture of an organisation is not something that happens quickly. It needs workers who understand the power of their own professionalism and the power of a trade union to defend its members from any local bullies and from the bullying target culture of central government.
Independent Inquiry into care provided by Mid Staffordshire Foundation Trust: January 2005 – March 2009, chaired by Robert Francis QC available at www.midstaffsinquiry.com.