Can we learn from the Mid-Staffordshire Inquiry or is it always someone else's problem?

Abstract

Key messages

• Every healthcare practitioner has a responsibility to put the well-being of patients first.

• Every healthcare practitioner has a responsibility in the maintenance of healthcare quality and each must take appropriate actions when alerted to poor standards.

• You cannot assume others will follow up patient concerns and take appropriate actions – the ‘buck’ stops with every practitioner on a professional register.

Why this matters to me

The regrettable events at Stafford Hospital were avoidable and reading the inquiry report highlighted the extent to which the NHS, and those within it, neglected their duties of care. I was particularly ashamed of my Registered Nurse colleagues who appear to have forgotten that registration as a nurse requires attitudes and behaviours commensurate with the public trust that is attributed to their role.

The shocking truth that emerges from the Francis Report¹ is that no organisation or profession emerges with any credit whatsoever – the Deanery, universities, general practitioners (GPs), the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), Monitor…. It is clear that any number of healthcare professionals could have challenged what was happening and alerted the relevant regulatory and supervisory organisations. Those organisations could have then discharged their ‘duties’ rather than taking a benevolent and optimistic view of the emerging evidence and leaving it to others to act.

The Francis Report noted that the events at Stafford Hospital have probably occurred elsewhere and will be repeated unless the healthcare system, and those within it, act differently in the future. Indeed, Keogh's review of 14 other hospital trusts with high mortality confirmed that the problems at Stafford Hospital were not unique.² The Mid-Staffordshire NHS Foundation Trust was caught in a perfect storm with a focus on financial and delivery targets at the expense of everything else, coupled with a tolerance of poor care and a ‘culture of habituation and passivity’ despite increasing evidence of neglect and suffering. In other words, it was a system failure in which individuals within the system played their part, with warning signs failing to elicit appropriate action from the range of external agencies in contact with the hospital. Indeed, the absence of cross-boundary thinking and alliances associated with integrated care delivery was striking. This lack of effective working across boundaries is not unique to the UK – Crisp³ has recommended that the NHS learn from other health systems how healthcare professionals practice and operate within systems so that they can better manage the interface between different components of the health system.

Although the Trust's senior management and its Board clearly bear responsibility for many of the disastrous decisions taken, it is interesting that GPs only expressed concern about the Trust after the HCC [now the Care Quality Commission (CQC)] investigation following poor patient survey results. The Francis Report recommended that GPs undertake a monitoring role on behalf of their patients; in particular, that they assess the outcomes of care so that they can help patients make informed choices about their referrals to hospital. It appeared that the local GPs did not maintain a continuing relationship with their patients, but rather saw the referral to hospital as an end point of their responsibility. If GPs are to be effective commissioners of services that are safe and of consistently high quality, they need to view their relationships with patients as long-term partnerships and develop their cross-boundary working by building relationships between disciplines and organisations within the local health economy. Aungst et al.⁴ referred to this as boundary spanning – a process by which connections are formed that blossom into meaningful relationships to promote effective health and healthcare. Moule et al.⁵ support Ara Darzi's⁶ cogent call for the development of integrated care for London's population, which if realised should ensure that Londoners are assured of high-quality care – regardless of the setting in which it is delivered – as there will be continuous conversations founded upon trusted relationships between people working in the different organisations.

Community nurses could also have voiced concerns when they heard whispers or worse about their local hospital in Stafford. It is most likely that discharged patients will have shared their recent hospital experiences during their ongoing care consultations with healthcare professionals, but it seems that no one took these complaints or concerns seriously. Indeed, the Francis Report¹ is full of examples in which the concerns of patients and patients’ relatives were not taken seriously and the healthcare system connived in its defensiveness and culture of secrecy to neglect its gaze and responsibility in maintaining the quality of care of patients. It is to be hoped that the lessons from the Francis Report will enable practitioners to have the courage and tenacity demanded of their professional status to be the guardians of their patients in all care settings, including care homes.

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