“The patient voice was not heard or listened to” #Francis

I don’t know how many people over here in the United States are aware of the release of the Francis Report on the investigation into abuses of eldercare in the National Health Service (NHS) in the UK.

The Mid Staffordshire NHS Foundation Trust Public Inquiry: Report: http://www.midstaffspublicinquiry.com/report

The briefest possible overview is this twenty minute Chairman’s Statement, which was read aloud by Mr. Francis, expressed with a strong sense of respect and emphasis.

Mid Staffordshire NHS Foundation Trust Public Inquiry: http://www.youtube.com/watch?v=4lySJlm1EnM#!

This particular report focuses on an investigation into abuses in a single facility, however the abuses and risks described could happen anywhere. It sounds horrific, but at the end, what is described is a series of checks and balances that failed, and failed at every step along the way.

I was myself in similar situation on a much smaller scale prior to one of my surgeries. There were problems with my care, and with communication around my care. I followed all the appropriate processes, kept clear records, walked through all the levels of support available to patients, and reluctantly filed a formal complaint at the hospital. That complaint would probably have been overlooked for some time, except that I happened to have a dear friend in a position of influence who enquired of the CEO what he thought about my letter. He hadn’t seen it yet. You can imagine what happened next.

At the end, the Chair of the Department explained to me what had happened, how, and why. I asked, “Did I do anything wrong? Is there anything I could have or should have done different that might have prevented things going this far?” I was told, “Absolutely not. You did everything exactly right. We were the ones who messed up. There are failsafes in place to prevent this from happening, but the failsafes failed. Each and every one of them. It was as if you hit every single crack in the wall, all the way down. Now, it is my job to find every one of those cracks, and fill them.” This was said with hand gestures illustrating all the cracks. The final sentence was said with such grim determination that I was very grateful that I don’t work in that department. Then, I was thanked, because of my clear records and communications, this was caught before something disastrous happened. The Chair said, “We can’t know how many other patients unfortunately had to suffer through things like this. But because of you, the patients that come to us in the future won’t have to.”

The point is that while you read the rest of the information about the Francis Report, keep in mind that this TRULY can happen anywhere. In the very finest hospitals, with the finest clinicians and nurses. It could happen to you. This is not simply something that happened because of intrinsic flaws in the UK healthcare system, and we are not spared because we are in the American healthcare system. And for that reason, I sincerely hope that every hospital administrator will read the Francis Report and consider how the findings might be implemented in their organization. I hope the doctors and nurses and patients will read at least the excerpts and highlights and consider the implications for the work they do. I hope that patients and scientists and the public take note of important role of transparency in PREVENTION of abuse and the PRESERVATION of trust. This is not simply a wake-up call or warning to the NHS, but to all healthcare systems.

Here is a very terse description of the abuses.

“There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.”
Robert Francis, Chair. Executive Summary, The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chairman’s Statement (PDF).

As you might imagine from reading that paragraph, what brought their attention to the issues was an unusually high mortality rate. In plain language, people were dying for lack of care, lots of people. The fundamental reasons discovered came down to these:
the almighty buck (“corporate self interest and cost control”)
weak leaders (“The Trust Board was weak.”)
laziness (“lack of professionalism” and “a tolerance of poor standards and the consequent risk to patients”)
CYA (“It defended trusts rather than holding them to account” and “It preferred to explain away concerns such as those about high mortality rates rather than root out matters which would concern.”
silence (“a failure to communicate known concerns” and “The dangers of the loss of corporate memory from major reorganisations were inadequately addressed”)
misguided priorities > ‘we need to look good’ (“It was a culture which trumpeted successes and said little about failings.”)

The fundamental synthesis of the 290 recommendations for change came down to this: To build trust, we need standards, openness, support, leadership, information.

“We need a patient centred culture, no tolerance of non compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing, and useful and accurate information about services.” (op cit)

Here are just a few phrases that leapt out at me as I was listening to the video.

“Nursing needs a stronger voice.”

“[I]nformation is the lifeblood of an open transparent and candid culture.”

“So called “gagging clauses” which might prevent a concerned employee or ex employee raising honestly held concerns about patient safety should be banned.”

“Trusts* must be open and honest with regulators. It should be an offence deliberately to give them misleading information.”
* Trusts are roughly similar to advisory boards or governing boards in the US.

“A common culture of serving and protecting patients and of rooting out poor practice will not spread throughout the system without insisting on openness, transparency and candour everywhere in it.”

“[P]atients come first.”

Please read more. Links are given below to the official documents, and there is of course an enormous uproar on Twitter (hashtag #Francis) and in the blogs. There is one particular blogpost that is getting a good bit of positive feedback from people there. Roy Lilley is less than encouraging about the likelihood of real lasting change resulting from this. He closes with this insightful statement.

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”
Roy Lilley. A few more F words: http://myemail.constantcontact.com/A-few-more-F-words.html?soid=1102665899193&aid=4IulmxtS6K4

Executive summary
Volume 1
Volume 2
Volume 3
Inquiry facts and figures


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