OFSTED style ratings for hospitals are not specific enough for patient procedures, Francis says

BMJ 2013; 346 doi: (Published 16 May 2013) Cite this as: BMJ 2013;346:f3194
  1. Nigel Hawkes
  1. 1Birmingham

Rating hospitals in the same way that the Office for Standards in Education, Children’s Services, and Skills (OFSTED) rates schools—an idea proposed by health secretary Jeremy Hunt—“may help” but doesn’t go far enough, Robert Francis QC told the National Institute for Health and Care Excellence (NICE) conference on 15 May.

The lukewarm response by the author of the highly critical report into Mid Staffordshire NHS Foundation Trust was echoed by David Prior, Hunt’s own appointment as chair of the Care Quality Commission.

“OFSTED ratings of overall hospital performance are not enough,” Francis said. “If I’m going into hospital for a treatment, I want to know how it performs at that particular procedure.” Prior said: “A rating of a hospital as an institution has a value but it’s limited. You also need a specialist rating for individual services. That’s more likely to be good if the institutional rating is also good.”

Francis said that he had been “really encouraged by the individual and collective response” to his report from the front line, which he believed had demonstrated a real will to change the culture. He was also pleased that the government had not rushed its response. “Government changes take time, you may need legislation, so I’m glad there wasn’t a rush,” he said. “Debate is good, but it should eventually come to a conclusion. If it doesn’t, a real opportunity will have been lost.”

In producing his report, he said his great surprise was that at Mid Staffs, “really basic stuff” had been forgotten. “The regulators didn’t recognise this. That is why basic standards must be developed, though it’s not for me to propose what they should be. Once identified, it’s up to NICE to generate a consensus about how to achieve them.”

At Mid Staffs, he said, people in the hospital were insulated from what was happening in other departments. These barriers needed to be broken down, and should not be tolerated. “Go home and do it,” he urged the audience.

He added that while his first report on Mid Staffs had been all about patients, his second focused more on how the patient voice had been diluted. New ways were needed to ensure that the patient’s voice was heard.

Prior said that the new Care Quality Commission was the next step in a process that began with the Darzi report of 2008, which focused on achieving quality in NHS care. “The Francis report gave us the compelling argument that Darzi had to be done,” he said. “Jeremy Hunt has given the Care Quality Commission the resources to make sure it is done. I am sure we can do it a heck of a lot better than it was done before.”

Ben Page, chief executive of Ipsos MORI, told the conference that, remarkably, neither the Mid Staff scandal nor the row over NHS reforms had much effect on public satisfaction with the NHS.

“People are able to separate individual incidents from their overall view,” he said. The same had been seen in public opinion over the racist murder of Stephen Lawrence in London. Although people recognised that the Metropolitan Police had handled the inquiry appallingly, this did not affect their overall view of the police; nor did many accept, as an official inquiry found, that the police were institutionally racist.

There was no settled public view, he said, over whether private involvement would make the NHS better or worse: people judged by their own experience, not by ideological conviction. A vote taken in the hall showed that the audience at the conference held much the same view, with only 13% voting that private involvement would make the NHS “much worse,” against 19% voting that it would make it “much better.” The majority of voters believed that private involvement would make little difference, for better or worse.

However, Page warned that equable public views on the reforms could change if experience of the NHS worsened. Improvements achieved by the Labour government did not lead to higher NHS approval ratings at once; it had taken several years. The opposite could happen—but it would not depend on media fuss, or parliamentary arguments. “It will depend on delivery,” he said. “There could be a tipping point.”


Cite this as: BMJ 2013;346:f3194