In this slideshow, Sally Williams, Independent Health Policy Analyst and Researcher, presents findings from the Nuffield Trust report: The Francis Report: one year on, which looked at how acute trusts in England have responded to the Francis Report after one year. Sally Williams spoke at the Nuffield Trust event: The Francis Inquiry: the impact one year on in February 2014.

1. 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

2. 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

3. 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

4. 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

5. © Nuffield Trust

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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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17 February 2014
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