Tuesday, 9 March 2010

Lessons for everyone

“If there is one lesson to be learnt, I suggest that it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented”.
Robert Francis QC
Chairman of the Mid Staffordshire NHS Foundation Trust enquiry

The Francis report is a lesson in communication – well written and easy to read but remarkabley disturbing. The patient stories that make up volume 2 deserve to be read by anyone seeking to understand the impact of poor care on those who seek help in hospital and on their families.

“There were often only 2 nurses for as many as 24 patients, and on occasion there was only 1 nurse attempting to treat everyone on the ward”

“I cannot believe that my husband spent his last few days in such an uncaring and appalling environment”

“On one occasion she attended the hospital at about 6.00am to find her mother in a side room calling ‘please help me, please help me’”. The patient was covered in dried faeces and was completely naked. She ran down the ward to find the staff “chatting and laughing”. She assisted on washing her mother and it was “awful”. Her “hands were absolutely caked” and it “was dried and it was all up her arms and it was round her neck”.
The patient died later that night.”

“The least important people on these wards were the patients”.

The report found a culture where patients were reluctant to insist on receiving basic care for fear of upsetting the staff, the consultant body was largely disassociated from management, where there was lack of openness and target driver priorities.

“Safety is the responsibility of all staff, clinical and non clinical”. Lord Darzi defined safety and quality as the organising principles of the NHS. Robert Francis quotes 4 earlier reports on safety beginning with Sir Ian Kennedy’s enquiry into children’s deaths in Bristol. Francis states “it should have been obvious to any Trust management between 2006 and 2009, if not before, that a high priority was to be accorded to patient safety in all its aspects”. In mid Staffordshire the Board concentrated on financial balance and achieving Foundation Trust status rather than quality of care. There was a focus on process at the expense of outcomes, a failure to listen, lack of support for staff and a weak professional voice in management decisions. I would encourage everyone to read the executive summary and the chapters on safety, record keeping and communication. Francis makes 18 recommendations. They are all directed at the Board, the Trust Management, Secretary of State, Department of Health and Monitor apart from recommendation 13: all wards admitting elderly, acutely ill patients in significant numbers should have multidisciplinary meetings, with consultant medical input on a weekly basis and recommendation 18: all NHS Trusts and Foundation Trusts should review their standards, governance and performance in light of this report. Many of the insights and comments are relevant to kidney care and indeed all care. Our understanding of human behaviour can be improved by appreciating how people systematically go wrong. Two things shouting out from this enquiry for me are the importance of encouraging our public and patients to expect and demand quality as a right and the important leadership role that all clinicians have as the custodians of quality for individuals and groups of patients.