Robert Francis's report published in February 2013 builds on his previous report from 3 years earlier. This time he focuses on the broader system failures and includes 290 recommendations for change covering 5 broad themes;
- Rigorously enforced standards
- Openness, Transparency and Candour – underpinned by a statutory duty of Candour
- Improved support for compassionate, caring, nursing
- Patient-centred healthcare leadership
- Accurate, useful and relevant information
In terms of ‘standards’, he describes two types - Fundamental including patient safety, effectiveness and patient care; and Enhanced – commissioner developed standards looking at quality and effectiveness over and above ‘Fundamental’ standards.
In terms of ‘nursing’ he suggests key changes, as follows;
- Assessment on entry
- Adoption of new training standards
- Adoption fo the Named Clinician role
- Healthcare support workers to be supported by common standards and code of conduct
- Nursing to have stronger voice
His message is “Every single person and organisation within the NHS, and not only those whose actions are described in this report, need to reflect from today on what needs to be done differently in future”.
So, faced with 290 recommendations, and nearly 2,000 pages of print, how are NHS organisations responding? In the weeks since its publication, we are seeing a genuine wish to respond to the report; but a real concern about how to achieve this whilst delivering current services and making significant improvement in service quality and reducing costs. Our view is that it will take some innovative thinking and system change to deliver this.
Let’s take one example – nurse training.
We detect real concerns currently about a disconnect in the experience of nurses in training from the realities of delivering care on the ward – typified by the phrase ‘too posh to wash’. However stereotypical the phrase, the current system for training nurses, unlike other health professions, does keep students at arms length from delivering care during training; also, where attachment to hospital is undertaken, there can be little consistency in where the student is allocated.
Some simple changes to the syllabus, a focus on practical work during placement and more consistency in placement will mean that students can effectively become part of the ward team and deliver care. This will enable an earlier exposure to the care and compassion required under Francis; but will also enable a more effective distribution of workload between students and Healthcare Support Workers, potentially reducing operating cost. The coalition Government has suggested something similar in it proposal to require students to become HSWs for 12 months before qualifying. We think this might be a step too far and feel that a more organic programme, along the lines described above, would have a greater chance of success.
Of course, it would not be sufficient to leave the process of change there; those nurses already qualified will need to be part of a broader cultural change programme as well. But, making some relatively straightforward changes to the training of student nurses is an example of thinking about the ‘system’ can be used to start addressing problems that otherwise might just be seen as too big to handle.