Culture change: Robert Francis’s prescription for the NHS

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f979 (Published 13 February 2013) Cite this as: BMJ 2013;346:f979
  1. Tony Delamothe, deputy editor
  1. 1BMJ, London WC1H 9JR, UK
  1. tdelamothe{at}bmj.com

Easy to recommend; almost impossible to implement?

For several years we have known what went wrong at Mid Staffordshire NHS Foundation Trust, and why it happened. From the Healthcare Commission’s report (2009) and Robert Francis’s first report (2010) we learnt of appalling examples of nursing care and an extra 500 deaths that occurred between 2005-06 and 2007-08.1 2 We know that the appalling nursing was caused by the trust cutting its already depleted nursing establishment to build up a war chest in preparation for its application for foundation trust status. In the process, the board had become fixated on finance and targets to the detriment of patient care.

And we know why the trust was pursuing foundation status with such despatch: considerable pressure to achieve this goal was coming from the very top of government all the way down to trust level. Of course, this experience was not unique to Mid Staffs, although its response may have been. What we haven’t known is why the regulatory agencies that festoon the healthcare landscape failed to identify this apparent outlier.

This is the gap that Robert Francis’s second report, published on 6 February, aims to fill.3 He identifies several reasons why the warning signs were missed, with “a culture focused on doing the system’s business—not that of the patients” heading the list. And it is therefore cultural change that Francis prescribes as treatment for the NHS’s systemic failings.

The NHS’s culture lies at the heart of Francis’s report and is arguably its real topic. As Francis states, an organisation’s culture is set from the top—in this case, the Department of Health. And it’s true that some of the behaviours of the Mid Staffs board are discernible in the unflattering descriptions of the Department of Health by Francis and others.4 5 6 But Mid Staffs was apparently in a class of its own. For example, the separation of ward from board was so complete there that the cries and smells emanating from the wards never registered above.

Francis wants the NHS to put patients first in everything it does and has drafted 290 recommendations to this end. But there are problems with the sheer number of recommendations and the mantra of putting patients first.

Despite being articulated so many times before, it remains stubbornly resistant to adoption. “Patients must be at the centre of the NHS and thus the patient’s perspective must be included in the policy, planning, and delivery of the services at every level” was one of the principles underlying the recommendations of the Bristol Inquiry 12 years ago. The General Medical Council has been exhorting doctors to “make the care of your patient your first concern” since at least 2006. If it hasn’t happened already, why should it happen now?

Could doctors at Mid Staffs have acquitted themselves any better? They didn’t do badly if you consider the competition; in this tragedy, managers and nurses played the leading roles at the trust. “It was striking,” concluded Francis’s first report, “how many accounts related to basic nursing care as opposed to clinical errors leading to injury or death.” Clearly, however, doctors should have pursued their concerns with management more vigorously, instead of keeping their heads down. One told the inquiry that managers told consultants who did complain regularly to “get back in their box.”

Francis was bemused that no clinicians took their concerns to higher authority; some seemed unaware of the existence of the Healthcare Commission (the Care Quality Commission’s precursor). One doctor’s reluctance may be explained by the fact that he had already been suspended for raising concerns about patient safety (now such a common response to criticism5 that one wonders whether it has found its way into management handbooks). Doctors will be looking for one of the legacies of Mid Staffordshire to be a legally sanctioned escalation process for expressing concerns about patient safety that haven’t been adequately dealt with by employers.

Some have expressed disappointment that no doctor has yet been struck off for what happened at Mid Staffs. The General Medical Council’s deliberations continue, and it may yet emerge that no doctor meets the criteria for this extreme sanction. Show trials, however, can serve only limited ends, says Francis: “To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary. That is certainly not the case here. To focus, therefore, on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm.”

Something Francis doesn’t dwell on in his report is the similarities between the financial circumstances of the Mid Staffs trust in 2005-06 and those of trusts today, struggling to meet the “Nicholson challenge” to save £15bn (€17.4bn; $23.4bn) to £20bn over three years. It was the need to save money fast that set the tragic course of events in motion.

Francis’s goal is for the NHS to learn from the lessons set out in the 2234 pages of his two reports and to adopt a new culture. On the day his latest report was released it was announced that five hospitals were being investigated for high hospital death rates, and earlier this week it was announced that another nine would be joining them. The government may have already decided that cultural change will be too hard and take too long.


Cite this as: BMJ 2013;346:f979


  • 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: Not commissioned; not externally peer reviewed.

  • The BMJ cluster of articles on Mid Staffs can be found at: www.bmj.com/about-bmj/article-clusters/mid-staffs.