Culture change: Robert Francis’s prescription for the NHS

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f979 (Published 13 February 2013) Cite this as: BMJ 2013;346:f979

Re: Culture change: Robert Francis’s prescription for the NHS

A culture of patient-centred openness and transparency could be promoted by changing some record keeping methods. This would be based on an approach that can be followed more easily by patients and their supporters and which has been taught for many years [1]. The approach can be applied very easily during electronic prescribing and other forms of electronic ‘requesting’ by offering a list of diagnostic indications to choose from. Choosing the diagnostic indication would result in another list of findings appearing that are related to that diagnosis. The same system could be used for requesting tests, nursing processes, etc. A computer system supporting this approach could then produce a summary that linked each of the patient’s findings, treatments and other actions to the appropriate diagnosis.

Such summaries would be ‘transparent and patient-centered’ and could follow patients from ward to ward and then home. They could be viewed by patients’ or their supporters if they wished to compare what was intended with what was actually being done. Such ‘transparent and patient-centered’summaries could provide a foundation for a new NHS culture of patient-centred transparency [2] and candour in the form of an audit trail if things went wrong. If a summary of this kind were updated each time the patient’s management plan was changed, then it would provide a check to reduce errors, others might also be able to notice errors before much harm was done.

This type of summary is more informative than other summaries because unlike them, it links each finding clearly to the relevant diagnosis and each diagnosis to its relevant treatments or other actions. This is what makes it ‘transparent’ and easier for everyone to understand.


1. Llewelyn H, Ang AH, Lewis K, Abdullah A. The Oxford Handbook of Clinical Diagnosis, 2nd edition. Oxford University Press, Oxford, 2009.

2. Mid Staffordshire NHS Foundation Trust. Public inquiry—chaired by Robert Francis QC. Final report. 3 volumes. 2013. www.midstaffspublicinquiry.com/report

Competing interests: No competing interests

20 February 2013
Huw Llewelyn
General physician and endocrinologist, Hon Fellow
Aberystwyth University
Aberystwyth, Ceredigion, SY23 3BZ. Email: hul2@aber.ac.uk