Intended for healthcare professionals


Culture change: Robert Francis’s prescription for the NHS

BMJ 2013; 346 doi: (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}

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 …

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