Sentry Page Protection

Medicine Interview Hot Topics: The Francis Report

​
​Overview

Robert Francis QC is a barrister who specialises in clinical negligence claims. He was selected to chair a public inquiry into poor care at Mid Staffordshire Foundation Trust, between the period of January 2005 and March 2009, and how problems were allowed to persist for so long without any organisation responsible for managing the trust or clinical standards noticing them.

The inquiry was held in 2010-2011, and its findings published in a document widely referred to as the Francis Report.


Why was the report necessary?

Poor standards of care were exposed at the Stafford Hospital, making national headlines in 2009. A local campaign group called for a public inquiry into the events, and how they could have happened in the NHS. They also claimed that a previous independent inquiry was not fit for purpose, and had not been transparent with its results.

The Healthcare Commission was the body that did manage to expose appalling treatment and very high mortality rates at Stafford Hospital. Around 400-1200 people had died unnecessarily there in just three years, according to media reports. It should be noted that these figures were not officially published by any government body or commission. Robert Francis estimated that the deaths numbered around 500. Patients were left in soiled beds, not provided their food or drinks, falls were hidden from relatives, and urgent call bells were left unanswered. The Accident & Emergency department was relying on receptionists to triage patients, rather than nurses and doctors. Relatives of patients complained of poor treatment by nursing staff, especially if they tried to raise issues about the poor standard of care.

A level of understaffing at the hospital appears partially to blame for the problems, although doesn’t appear to begin to cover the attitude of many of the healthcare workers there. A culture of bullying was also present, with senior managers clamping down on any workers who tried to bring problems to greater attention. Management ignored staff concerns largely because to deal with those concerns would have damaged the hospital’s finances.

Wards were organised as ‘clinical floors’ in an effort to save money. Registered nurses were outnumbered by healthcare assistants in a ratio of 40:60.

It appeared that the managers were more focused on the trust attaining foundation trust status, than on the quality of care it provided its patients, which was specifically noted by Francis in his first report. The report would state: ‘the inquiry chairman, Robert Francis QC, concluded that patients were routinely neglected by a trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care.”


What will change?

The government has responded to the Health Select Committee report After Francis: making a difference, and to various other groups’ findings. Through looking at these findings we can understand the changes that must be made. Healthcare assistants’ training must be improved to ensure that they can provide care of the highest standard. Complaints about care in NHS hospitals must be listened to and acted on, without any fear of retribution or bullying of those that bring complaints to the attention of their managers or external bodies. There should be efforts made to reduce bureaucracy and the bureaucratic burden. There should be a greater focus on the health outcomes of young people. Patient care must be improved, even if budgets do not increase. This means improvement of care models, improvement of the partnerships between clinicians, patients and carers, with the goal of producing better care at a lower cost through greater cohesion.


Example Interview Questions 
​
  • What is the Francis Report?
  • Why was the Francis Report commissioned?
  • What can you tell me about the failings of care at Stafford Hospital that led to the commissioning of the Francis Report?
  • What do healthcare assistants do? Do they have to have qualifications?
  • How can we improve the standard of patient care without dedicating huge amounts of additional funding to a hospital, or the NHS as a whole?
  • How does understaffing lead to poor patient care?
  • Do you know what kind of changes are expected as a result of the Francis Report? What changes might you want to instigate if you were in a position of authority?
    ​


Interview Questions & Example Answers
​


What is the Francis Report?

The Francis Report is named for its chair, Robert Francis QC. He is a barrister who specialises in clinical negligence and was chosen to chair a public inquiry into allegations of poor care at the Mid Staffordshire Foundation Trust. The allegations spanned the period from January 2005 - March 2009, and seemingly persisted without being noticed or addressed. The inquiry was held between 2010 and 2011, and the findings published in a document that came to be known as the Francis


Why was the Francis Report commissioned?

The report was commissioned in light of poor standards of care at Stafford Hospital, that were exposed by the Healthcare Commission, and by the press, in 2009 and made national headlines. A local campaign group made calls for a public inquiry into the events, claimed that a previous independent inquiry was not fit for purpose, and that the previous inquiry had not made its result clear. Due to the campaigns and negative press attention the Report was commissioned - and these of course stemmed from the poor care (with as many as 500 unnecessary deaths estimated there by Robert Francis over the course of just three years).


What can you tell me about the failings of care at Stafford Hospital that led to the commissioning of the Francis Report?

Around 500 people died unnecessarily over the course of three years - between 400-1200. Patients were left in soiled beds, falls were hidden, urgent calls went unanswered, and patients were routinely left without food or water. The A&E department relied on receptionists to triage patients.

Nursing staff treated patients and their families poorly, especially if complaints were made. Understaffing appears to have been a real issue, with registered nurses outnumbered by healthcare assistants in a 40:60 ratio. Managers appeared to be more focused on the Trust’s status than on the wellbeing of its patients.


What do healthcare assistants do? Do they have to have qualifications?

Healthcare assistants work to assist medical teams, and specifically assist nurses in the day-to-day running of wards and GP surgeries. From the RCN website, we are told that ‘there are no specific national requirements to becoming an HCA. You simply need to be passionate about working with people and be caring and compassionate.’ Training is provided on the job, and therefore reliant entirely on the ability of the employer to provide training - i.e. there is no ‘safety blanket’ over core knowledge from previous education at university, nor is there a period of true initial training in which certain core competencies must be learnt and examined.


How can we improve the standard of patient care without dedicating huge amounts of additional funding to a hospital, or the NHS as a whole?

This debacle gives a good overview of how patient care can be improved simply through the actions of individuals, without huge investment into the NHS. A culture of bullying pervaded throughout Stafford Hospital, which was seen in both the way that nurses talked to patients and their families, and the way in which healthcare workers were treated by managers when they tried to provide feedback or enact change. If the hospital had had better protocols in place for communication, leading to more integrity and honesty from its workforce, then patient outcomes would have improved - as would the working environment.


How does understaffing lead to poor patient care?

Understaffing means that a given patient will likely not receive the care they need at the correct time. It may manifest itself as a late appointment, a test arriving late or being dispatched late, or a patient on a ward finding that their food arrives late. Understaffing will also lead to a tired and stressed workforce, who in turn are more likely to make serious mistakes - mistakes that could cost patients their lives. Additionally, an exhausted workforce is less likely to be able to be compassionate, to show integrity and good communication skills both with each other and with patients, or to be able to take the time to work thoroughly and diligently on a case that is complex or challenging.


Do you know what kind of changes are expected as a result of the Francis Report? What changes might you want to instigate if you were in a position of authority?

The government explained that in light of the report, the training of healthcare assistants would be improved. It explained that complaints about care in NHS hospitals must be listened to and acted on, and that this process must be made easier for those that feel they need to have their voice heard. If I was in a position of authority, I would also seek to reduce the bureaucratic burden of the NHS, through greater leadership in the hands of clinical staff and less management presence. I would focus too on methods to improve interdisciplinary care, so that all parts of the NHS worked together without fear of bullying, in greater cohesion than before. 
​