Francis interview: what doctors must learn from my reportBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f878 (Published 08 February 2013) Cite this as: BMJ 2013;346:f878
Robert Francis is a lawyer and therefore careful with his words and not prone to soundbites. It took him four volumes and 2000 pages to sum up his findings on Wednesday. His report unpicked an NHS culture that tolerated such appalling low standards of care at Stafford Hospital that 400-1200 patients died of neglect, misdiagnosis, and, to quote prime minister David Cameron, “horrific abuse.”
Speaking to the BMJ, Francis is clear that doctors at the hospital were part of this culture. Asked what doctors should take from his report, he says: “A consultant has a personal professional responsibility for the welfare of their patient, not just their liver and appendix or whatever, and if that consultant turns up [on the ward] and sees that the care being given to that patient is unsatisfactory then they have to do something about it. I suspect many do, but it’s a regrettable fact that some consultants at Stafford cannot have been doing that otherwise these things would have been spotted and stopped.”
In his first inquiry into the Mid Staffs scandal Francis identified a “fatalistic” attitude among doctors; they had lost faith in management, kept their head down, and got on with their job. This theme surfaced again in his final inquiry: “Clinicians did not pursue management with any vigour with concerns they may have had. Many kept their heads down,” the report says.
Some of that inertia was down to a fear of reprisals. A handful did blow the whistle, including Chris Turner, a junior doctor in the emergency department in 2007, who told the inquiry the department was “an absolute disaster” and “immune to the sound of pain.”
“It’s true, there were only very few,” says Francis, speaking to the BMJ in Westminster immediately after the launch of his final inquiry report. “Some doctors raised their heads at a consultants meeting, got a rebuff, and did no more. Some journalists today have asked why there’s not more in the report for whistleblowers, but a lot of what I’m saying is [for them].”
The report calls for a ban on gagging clauses in NHS contracts, and a new statutory duty of candour on staff to be honest and open about mistakes. If anyone wilfully obstructs staff from carrying out this duty—for example, a manager—then he or she should face criminal prosecution, says Francis.
Francis hopes his suggested new structure of minimum standards of care will give staff a benchmark—if they witness care being delivered below these standards they will be obliged to speak out. And if death or serious harm is caused by a breach of these standards then staff should be held criminally responsible.
Much of this will require legislation, and it remains to be seen which of Francis’s proposals Cameron will accept when he responds to the report next month. Francis knows this enforcement of individual professional responsibility to patients “will be unwelcome to some.”
He remains concerned that the General Medical Council doesn’t have the clout to flush out and censure failing professionals. In his response to the Commons on Wednesday, Cameron asked why, six years after the Mid Staffs scandal broke, not a single doctor or nurse had been struck off.
“Both GMC and NMC [Nursing and Midwifery Council] have in the past relied very largely on receiving complaints about identifiable professionals who they then haul in front of them after an investigation. But I don’t think either organisation has been sufficiently proactive in going out there and saying, there’s a problem at this particular hospital, let’s go there and find out who is responsible for it, rather than waiting for a complaint about an individual. There was some acceptance from GMC witnesses at the inquiry that this needed to be done.”
Francis thought that employers were too ready to use the GMC as a substitute for not getting involved in disciplinary action themselves. “The fact there is a [GMC] process in place is being used by employers as a reason for not taking other action to protect patients.”
But how practical are many of Francis’s 290 proposals in such a dire financial climate? Can the report be implemented under the resource constraints of the Nicholson challenge?
“It must be,” declares Francis, even if it means whole wards or services closing because trusts cannot guarantee safe delivery of care.
“Whenever trusts are making cost savings, you have to explain to the public how you are going to do that and not put patients at risk. You also need to have honesty so that if a service for whatever reason cannot be provided safely and comply with these fundamental standards then we don’t carry on doing it.
“That requires honesty and courage on the part of those who run these hospitals, but the medical and nursing profession have a big part in that by exercising their existing responsibilities to protect patients. We need to listen less to the argument, ‘Well if you are saying that, then it’s because you aren’t doing your job properly.’ Frankly if a service can’t be provided without intolerable suffering of patients, then it’s not a service at all and shouldn’t be provided at all.
“Frankly if we are to stop this happening again then we are going to have to make those hard choices.”
Lessons for primary care
And what is the take home message for general practitioners from this forensic report? The BMJ put it to Francis that local general practitioners clearly didn’t know what was happening at Stafford Hospital during 2005-09 otherwise they wouldn’t have sent patients there.
“It’s worse than that,” said Francis. “The evidence suggests that there were no complaints of any substance at all about Stafford until the Healthcare Commission announced it was undertaking an investigation. [GPs] were then asked by the PCT if they had any concerns. Within days they came up with letters full of concerns. So it’s not that [the GPs] didn’t have concerns but they hadn’t thought about it and put them together.
“It’s vital that GPs remember that their responsibility to their patient doesn’t end when they go into hospital. They need to be more systematic about how they gather information because, after all, they are meant to advise patients on where is the best place to go for their treatment. The old fashioned way of phoning up their friend the consultant and having a word is just not good enough.”
At the close of the day, Francis “can’t be confident there isn’t another Stafford out there” and cautions against any complacency.
“I’m sure many BMJ readers would say this patient centred culture exists in their practice, but that is not a reason for complacency because they should also have responsibility for ensuring their colleagues have the same culture.”
With the publication of his report, Francis has captured the 139 days for which the Mid Staffs public inquiry sat, including oral evidence from 181 witnesses.
His next challenge is on Tuesday, when he will be grilled by the Health Select Committee—the first time he has been cross examined over his findings. “Not a comfortable feeling for a barrister,” he smiles.
Cite this as: BMJ 2013;346:f878
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.