Anyone reading Robert Francis’ massive Report into the Mid-Staffordshire Hospital Scandal(1) will surely be appalled at the widespread failures which meant that hundreds of patients suffered whilst Regulators and bureaucrats vacillated. Its 290 recommendations challenge almost every aspect of the status quo and is a tough read for everyone associated with the provision of health and social care.

But specifically, what are the lessons for public and patient involvement?

Essentially, of course, this was a problem in one poorly-managed hospital. But the Report’s analysis shows without doubt that the inadequacies of public and patient involvement are more deep-seated and call for a radical re-think. Its coruscating criticism of ineffective replacements of Community Health Councils (CHCs) in England(2) leads to his expressing a concern that Healthwatch will be no better!

The Report confirms what Julie Bailey and others have claimed – that the bodies set up to express the voice of patients and the local community utterly failed. So did local authority Scrutiny Committees. Regulators did too little too late; MPs scarcely contributed and even the Media did precious little. Don’t heed any apologists. Apart from the doughty campaigners who have been rightly lauded, no-one emerges from this story with credit. It’s a shambles.(3)

Relevant recommendations

The Report makes 290 recommendations. Here is an abbreviated summary of those the Institute believes are relevant to those working in patient and public involvement:-

• Greater attention required to the narrative of complaints – not just numbers (No 40)
• Those with health oversight and Regulators should monitor the media (No. 43)
• MONITOR should promote greater patient & public involvement (No 62)
• Improved stakeholder consultation before granting Foundation Trust status (No 66)
• Ministers not to approve Foundation Trusts without regard to consultations (No 71)
• Constant promotion of encouragement of public comments and complaints (No 111)
• Patient feedback (other than complaints) expressing concerns needs quality investigation and feedback (No 112)
• Details of upheld complaints to be published on Trust websites (No 118)
• Access to complaints data to be available to Overview & Scrutiny Committees and Healthwatch (No 119)
• In measuring against indicators, Commissioners require close engagement with patients, past present and potential (No 129)
• Commissioners have to engage & involve communities – including having a consultative process and undertaking surveys (No. 135)
• Commissioners need ‘knowledgeable and skilled local personnel engaging with an informed public’ (No 136)
• HealthWatch should have a ‘consistent basic structure’ (No. 145)
• HealthWatch funding should be ring-fenced. (No. 146)
• Guidance required to promote co-ordination between local Healthwatch, Health & Wellbeing Boards & Council Scrutiny Committees (No.147)
• Training needed for leaders of local Healthwatch (No.148)
• Support required for Council Scrutiny committees … inc guidance & benchmarks (No149)
• Scrutiny committees should have a power to inspect and to follow-up others’ inspections (No 150)
• MPs, when processing constituent complaints need to look for trends … (No 151)
• Surveys of medical students and trainees’ perceptions re patient care required through the GMC and CQC (No 159)

Wise words

The Report contains much that interested parties should heed. Here are 5 quotations:-

About the Staffs Health Overview & Scrutiny Committee:-

It made no attempt to solicit the views of the public. It had no procedure which would have encouraged members of the public to come forward with their concerns.”

(Par 6.350)

On the inadequacy of Council Scrutiny committee minutes:-

“While a Hansard-style transcript is not required, it is unfair to the Councillors and obstructive to public engagement for there to be no record of the contributions made by committee-members … and of the responses given. The essence of public engagement is that their views are captured to inform the decision-making process within the service. This requires the recording not only if an outcome but also of the range of views expressed.”                                                                                   (Par 6.202)

About the limitations of engagement/involvement structures:-

“Local opinion is not most effectively collected, analysed and deployed by untrained members of the public without professional resources available to them”   (Par 6.466)

Upon survey results having indicated that all was not well in Mid-Staffs:-

“  … the reaction was to look at the results as numbers to be improved if possible rather than to examine the underlying causes.”

“An approach to this sort of survey that accepts AVERAGE as acceptable or takes comfort from a majority of positive responses when the proportion of negative ones indicates a significant number of substandard episodes of treatment is likely to leave large numbers of patients being cared for badly.”                                             (Par 6.451)

 

The Institute View

 

• Even this Report – and its widespread acceptance may not fully do justice to the scale of the current challenge for public and patient involvement in Health and Social Care
• The Report naturally is focused on Hospitals – but Primary Care and Social Care are equally in need of improved patient and public involvement
• Truly integrated health and social care requires a community-based approach, not an organisation-centred approach. Having separate units responsible for public engagement at Hospitals, CCGs (England) or Regulators may not work unless they are co-ordinated!
• Health & Wellbeing Boards therefore become pivotal. And they have to devote the resource to listening to their residents.
• Clinicians cannot delegate this to administrators, but have to be visibly active in consultative processes. They need training in current best practice on public engagement
• The public is losing faith – as seen in legal challenges and protests against NHS re-configurations. Campaigners and politicians will use social media to put Managers under pressure, so a professional response is much needed

Relevance
Those who believe that the lessons of Mid-Staffs are mostly for those working in the NHS are mistaken. 

Local Authorities have important responsibilities for Health and Wellbeing – and in England, take charge of Public Health from April 2013. Elected members and support staff likely to be involved in Health & Wellbeing Boards will need to keep up-to-date on the implementation of the Francis recommendations. These also affect Overview & Scrutiny Committees, Local Healthwatch and their support staff.

Regulators also have much to consider in the wake of this Report. Not only in Health are there risks if industry regulators neglect to engage with key stakeholders – and the general public.

Within the NHS, newly-formed Commissioning Support Units will be providing specialist help on patient and public involvement in England from April, and new structures are bound to take time. The Francis Report has important lessons for all involved in such issues, but it is important to disentangle the various strands of best practice advice, and to adapt them to the new organisation..

Further insights

•  This Briefing was written by Rhion Jones, Programme Director of the Institute, and who may be available for discussion. Telephone the Institute Centre of Excellence in Biggleswade on 01767 318350
• On 13^th February 2013 in London, the Institute is running a specialist event on The challenge of stakeholder engagement and consultation  – a new priority for Regulators . We have a few last-minute places available
• Poor practice such as found in Mid-Staffs needs to be eradicated through better consultations in the NHS. The Institute has developed a new management-game to help understand how best to manage reconfigurations. It is called Managing Strategic Change in Health & Social Care, and will be run In Birmingham on   27^th February.
• Also in Birmingham on 14^th May, the Institute will hold a special Roundtable called Will Health & Wellbeing Boards succeed in engaging communities? Much of this event will focus on the right response to the Mid-Staffs Inquiry

(1) The Mid-Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis QC – 6^th Feb 2013Briefing Notes are published by the Institute in good faith as a member benefit, but the information provided cannot be relied upon as constituting advice giving rise to any legal or other liability whether express or implied.

(2) CHCs were retained in Wales and have evolved. The Institute believes it is a good model, though challenging.

(3) CURE the NHS, the local pressure group arising from Julie Bailey’s activities is recognised by all as having played an outstanding role in bringing the failures in Mid-Staffs to public attention

This is the 8^th Briefing Note; a full list of subjects covered is available for Institute members and is a valuable resource covering so many aspects of consultation and engagement