How chief executives should respond to the Francis report

It has now been nearly six months since the Francis report came out. The government and all health related agencies have responded in greater or lesser detail to the findings of Robert Francis QC, and Mike Richards has been appointed as the chief inspector of hospitals.

‘The Francis report asks us to look closer and examine what we do in the culture we have created’

Some regulators have changed their terms of reference partially in response to the report but also as part of the 2012 Health Act. We now wait to see the recommended major changes enacted but some are apprehensive that the sheer size and inertia of the NHS will result in little change.

So what can be done? Those who know the NHS realise it’s not really one big monster but a very large number of smaller − but still pretty big − beasts. Each provider trust board is responsible for action in these circumstances. Trusts are led by experienced chief executives with a very explicit responsibility to deliver on quality. They may well understand quality governance but still might be anxious about how to enact all of the report’s 198 recommendations.

The Francis report asks us to look closer and examine what we do in the culture we have created, listen to our patients, not to tolerate mediocrity, aspiring to deliver the excellent service that our patients want and deserve.

‘There’s a lot more in the report that’s important to read first hand, even the parts you might not see as directly relevant to you’

He speaks of two main strands. First, a failed organisation with a corrosive culture that focused on delivering unsustainable short term savings to achieve a title and external approval at the cost of systematic neglect of patients’ needs. There was a weakness of leadership that allowed staff to disengage from their responsibilities or turn a blind eye.

Second, he describes a disjointed matrix of supervisors and regulators whose lack of organised communication allowed this to go unnoticed for so long, unknowingly encouraging a focus on target delivery at the expense of patient safety. The inspectorate was not able to see inside the trust with sufficient clarity to identify the cultural and structural failures that allowed individual personal failures to occur unchallenged.

Although the ultimate responsibility clearly rests with the trust board to ensure safe and compassionate delivery of patient care, chief executives should be the “care chief constables” in their own trusts. They are responsible for the values, culture and governance that ensure good care, even when services are heavily stressed.

So what should chief executives see as priorities right now? Here are some points to consider:

Read the report

Not only the executive summary, but the whole thing. Don’t be like some of your colleagues who have “too little time” and leave it to your governance lead or chief nurse to read and develop a template for the trust to assess itself against for the board report. There’s a lot more in the report that’s important to read first hand, even the parts you might not see as directly relevant to you. It’s truly illuminating to read how it is possible for multiple agencies to be interested in an organisation yet miss the big picture that demonstrates the problem at hand. Read it in chunks; take a fortnight.

Do something that focuses on patients

This should put patient opinion directly closer to the way you personally understand your trust. Invest a little of your own time seeking some direct evidence of the patient experience. Visit wards, clinics and community outreach clients. Try to make this a less presidential visit than it may have become. Sit on a chair next to the patient and see how different the world looks. Consider personally leading a focus group − invest in real time patient experience. There are a growing number of agencies, websites and more traditional organisations that will help you develop a lively flow of information on patient experience that allows you to respond directly and immediately to concerns and poor experience.

Read your complaints

They are a valuable, if sometimes unsettling, way of seeing how difficult it can be for some of your patients. They also are a good way of knowing how tricky it is for your staff to always deliver a high standard of care at every patient encounter. Periodically, make sure you spend a little time with unsatisfied complainants (there will always be some, no matter how good your trust is). Use this exercise to assure yourself that you are at the head of a learning organisation that seeks continuous improvement in a way that Don Berwick would be proud of.

Do something that makes it easier for staff to do their job with compassion

Your staff are key. Successful organisations invest in the satisfaction and training of their staff. Any indicator in the staff survey that implies discontent, disconnection with the trust or a sense of limited impact is an alarm warning of a deteriorating morale or an alteration in the culture away from patient safety. You can be sure that there is more than one of your staff who are frustrated on a daily basis by some kind of inefficient demand on their working day. Find one of these tedious demands and remove it. Encourage others to do the same. Make one troubling facet of that staff survey your personal objective to understand.

Invest in your safety and quality culture

There is so much evidence that a culture of continuous improvement saves lives that a lack of investment in this strategy at the highest level could be considered managerial negligence. It doesn’t matter if you choose to pursue a branded improvement philosophy such as “Lean” or something more prosaic or homegrown, it must be a visible credo of the board, founded on the principles of transparency, reporting, espoused at all times by the executive.

Even in times of fiscal difficulty it must be seen as a guide to service change rather than an impediment. Getting care right first time is always the most cost effective. Consider the MRSA and C. difficile stories of the past decade. Press your clinicians to show they are always seeking to adopt quality enhancements such as stroke best practice or enhanced recovery programmes.

Look at your senior leadership

Leadership has many definitions, but at its most elemental it is the mechanism by which the vision and strategy of the trust is created and then translated into the delivery of patient care. Poor leadership directly leads to poor care. Good leadership creates consistently high quality services.

It’s difficult to pull off and needs constant maintenance. It is no surprise many trusts struggle with breathing life into their leadership strategies (if they have one).

Accountable clinical leadership is at best an aspiration for many. Visible, decisive board leadership is hard to sustain for others. Use the leadership development available from the NHS Leadership Academy through its core programmes to improve teams and leadership at every level in the trust. Whatever you do, do something practical and sustainable that changes the way your organisation looks at and behaves towards your patients.

Dr Chris Gordon is programme director for QIPP at the NHS Leadership Academy