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Government responds to Stafford inquiry with new “whistleblower in chief” to rate hospitals

BMJ 2013; 346 doi: (Published 27 March 2013) Cite this as: BMJ 2013;346:f2030
  1. Clare Dyer
  1. 1BMJ

NHS hospital trusts in England will be placed under a statutory duty of candour to be open with patients and regulators if they believe that treatment or care has caused death or serious injuries, and organisations that flout the duty will incur criminal penalties.

The measure is part of a package of reforms aimed at creating a new culture of openness and safety in the NHS, after widespread institutional failings were laid bare by the public inquiry into events at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.

The public inquiry, which reported in February, painted a damning picture of a top-down culture in which patients were subjected to “appalling” care in the pursuit of management targets, while various regulators failed to pick up that the system was failing.1

Robert Francis QC, who chaired the inquiry, recommended that it should be made a criminal offence for any doctor, nurse, or director of a healthcare organisation to provide intentionally misleading information to a patient or nearest relative, to obstruct another person in performing the duty of candour, or to make a dishonest statement to a commissioner of services or a regulator.

Jeremy Hunt, health secretary for England, said that ministers were concerned that creating criminal penalties for individual doctors or nurses might contribute to a culture of fear rather than one of openness. But no decision has yet been reached, pending recommendations due in July from a panel headed by the US “zero harm” guru, Donald Berwick, to ensure that “a zero toleration of avoidable harm is embedded in the DNA of the NHS.”

From 1 April organisations commissioned to provide NHS healthcare, with the exception of GPs, will have to comply with a contractual (not statutory) duty of care. If an incident resulting in moderate or severe harm or death has or is suspected to have occurred, organisations will have to carry out an investigation as soon as possible and inform the patient or relative what went wrong.

Outlining the government’s initial response to the Francis report, Hunt said that it was dealing with “key early priorities” and that a more detailed response would come later. Ministers accepted most of the recommendations in the Francis report “either in principle or in their entirely.”

A new chief inspector of hospitals will be appointed this year, who will carry out deep investigations of hospitals, as long as a month, with expert inspectors. The chief inspector will act as the nation’s “whistleblower in chief” and will produce a new set of fundamental standards, working with the National Institute for Health and Clinical Excellence, patients, and the public, to make explicit the basic rights that anyone should expect of the NHS.

Hospitals will be given a single, clear rating of “outstanding,” “good,” “requiring improvement,” or “poor,” and outcomes will also be available for individual departments, specialties, care groups, or conditions.

Failing hospitals will be dealt with quickly, with a new time limited, three stage failure regime, encompassing not just finance but, for the first time, quality. If problems cannot be resolved, the board could be suspended or the hospital put into administration.

The merits of having a chief inspector for primary care is also being explored. There will be a new national barring list of unfit managers, preventing them from moving to other jobs in the NHS. And “paperwork, box-ticking, and duplicatory regulation” will be reduced by at least one third, to give staff more time to provide care.

Mike Farrar, chief executive of the NHS Confederation, which represents organisations that commission and provide NHS services, said, “The response finds the right balance between external assurance measures and internal changes focused on transforming the NHS culture.”

The healthcare think tank the King’s Fund questioned the value of aggregated ratings for hospitals but welcomed the proposal of ratings for specific services.

Mark Porter, chairman of council at the BMA, said, “We share the health secretary’s concerns that the threat of criminal sanctions for individual staff would be counterproductive and risk creating a new climate of fear.” He said that the new inspection regime needed “to avoid a system that encourages managers to focus unduly on ratings.”

National Voices, a coalition of health and social care charities, said that the statutory duty of candour, along with the ban on gagging clauses when employees leave the NHS, “should remove a huge chunk of the culture of cover-up—in this case, one which has been particularly harmful and distressing to patients, who have had to fight their care providers to get at the truth.”

AvMA (Action against Medical Accidents), the patients’ charity that campaigned for a legally enforceable duty of candour for more than 10 years, gave the decision to introduce it a “cautious welcome.” Its chief executive, Peter Walsh, said, “We want to know more detail, but I think we can be confident the government has listened.”


Cite this as: BMJ 2013;346:f2030


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