Richard Vize: Can the recommendations of the Francis Inquiry be implemented?

Richard VizeThe recommendations of the Francis Inquiry cannot simply be implemented. It is a complicated set of proposals that will create new difficulties and challenges for the medical profession. Doctors need to lead the debate on what happens next.

Robert Francis’s lawyerly circumlocution, filling almost 1,800 pages, guarantees that virtually nobody will read the whole report. Are public inquiry chairs paid by the kilogram? But at its core is the powerful concept of professionals adhering to “fundamental standards” to be enshrined in the NHS Constitution and health service regulations and policed by the Care Quality Commission. Crucially, Francis calls for “zero tolerance” of breaches.

As Francis makes clear in his interview with the BMJ, this means wards and operating theatres should be closed if they cannot meet the standards.

Assuming the government accepts this recommendation, the Department of Health will be consulting on it extensively. It is vital that the medical and nursing professions do not just participate in this discussion, but are publicly seen to take the lead in identifying what these standards should be and how they should be implemented.

This is, of course, complex territory for the medical profession; on paper at least the Francis report marks the beginning of a process to put more power back in the hands of clinicians. More certain is that it gives them more responsibility and risk.

At first glance, adherence to fundamental standards offers a bulwark against oppressive management and helps provide stronger clinical underpinning to decisions about the allocation of staff and money. But it is debatable just how much this will change what happens in trusts. How many consultants would be prepared to shut their service rather than struggle on with overstretched resources? In the post-Francis world they may well be seen to be under an obligation to close, but if that was pursued rigorously across the NHS just how many services would be shut? Rigid adherence to the fundamental standards regime does not remove problems so much as replace them.

Francis insists that non-compliance with a fundamental standard leading to death or serious harm “should be capable of being prosecuted as a criminal offence, unless the provider or individual concerned can show that it was not really practical to avoid this.”

There is increasing public and political appetite for prosecuting clinical and managerial staff for any failings, while the General Medical Council and Nursing and Midwifery Council face a clear expectation that they should initiate investigations as well as deal with complaints.

Alongside the call for a new standards regime, Francis demands that a culture of fear is replaced with one of openness, transparency, and candour, so that concerns can be raised freely, performance measures are published and the health service is honest with patients who have been harmed.

The culture of fear of management must not be replaced by a fear of prosecution for understandable human error—as opposed to incompetence or negligence. Again, the professions need to take the lead in promoting the highest standards of care while finding the right approach to enforcement.

GPs are again pushed centre stage. Francis sees them as patient champions, with a requirement to monitor the quality of the services that their patients receive. In an almost throwaway line which has significant implications for the way GPs operate, Francis says “they need to have internal systems enabling them to be aware of patterns of concern.” This suggests comprehensive service monitoring across the surgeries under each clinical commissioning group.

The debate on Francis is inextricably linked to moves to reconfigure hospital services. In particular, the safety and quality of surgery and A&E departments will come under renewed scrutiny. Both debates—Francis and service reconfigurations—require politicians and professionals to have a far more informative and honest conversation with the public about what constitutes quality in the NHS, and how best to achieve it.

Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.