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Robert Francis QC at CQC Board Meeting 31/07/2013Video YouTube http://youtu.be/4_CVKQCoZAs

Robert Francis QC chaired the Mid-Staffs NHS Foundation Trust Inquiry – often referred to as the Francis Inquiry.


Robert Francis QC

The Francis Inquiry or the Mid Staffs Hospitals Inquiry was set up as a response to the following context. Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust1 (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Monitor (the independent regulator of NHS foundation trusts) had subjected it to assessment. It appeared largely compliant with the then applicable standards regulated by the Healthcare Commission (HCC). It had been rated by the NHS Litigation Authority (NHSLA) for its risk management. Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. (Francis Inquiry, 2013: pg 7)

Robert Francis spoke at the recent CQC Board Meeting. Drawing on  his experience of the Francis Inquiry and meeting families he recommended the  ‘lessons learned’ for regulators.

  • Individuals should be listened to. Their experiences and stories should  not discounted. (My comment follows) Frequently in regulation individual complaints are put to one side  because they are not seen as a representative sample. A common assumption of inspection methodologies is to see it as a kind of research where only information derived from a random and neutral sample is valid evidence. Consequently, the value of individual complaints is reduced and the perspective they give on the secret life of institutions ignored or in Francis’s term ‘discounted’.
  • Assess safety impacts of information. Here he advocated a precautionary principle–act to avoid risks implicated in new information even if the evidence base can be argued as incomplete.  Unfortunately, the impact of the UK Better Regulation policies as been to abandon the precautionary principle. Regrettably, the criteria used to move away from precaution has been financial cost. It can be argued that, in moving away from the principle of precaution, risk impacts and costs have been shifted to end users of regulated sectors.
  • He comes down on the side of expert inspection;  inspectors should be expert in the context, skills and knowledge of the regulated area.   ‘Expertness’  is not always a good thing. It precludes the ordinary person; their testimony becomes non-expert. It is difficult to balance these positions but it would require additional skills and expertness in working with those using regulated services. Commentators on desirable qualities of inspectors have generally agreed on – expert knowledge of sector, knowledge and understanding of regulation and very good interpersonal and communication skills. The ability to work with citizens/lay people is an essential skill also. Stressing ‘expertness’ requires awareness of the wider range of skills necessary and implicit tensions. Inspector Knowledge is discussed in greater depth in our research click here.
  • He commented on the Francis Inquiry finding that regulators did not share information and tended to redirect complaints to other institutions. Regulators have obligations particularly to whistleblowers. See our post on Whistleblowing.
  • In health regulation the tendency has been to give generalised ratings (stars etc) to the institution as a whole. He was critical of such generalised ratings for large organisations such as hospitals which house many different, almost independent, clinics and specialisms. Patients and family, he argued, would be better served by knowing the rating for cancer care or maternity at a particular hospital.  Totally agree.
  • Finally, he counselled the CQC to be a role model for health organisations. He made reference to the reinstatement of Kay Sheldon on the Board and the need to show that whistleblowers are taken seriously and protected from vilification (see our article on Whistleblowing). He also made reference to bullying and the need to support staff. We would add that there is the need to empower staff and look again at top down management in regulation organisations.

CQC have done well to publish  video records of the Board meetings. They give exceptional insights and knowledge into the management of regulation, hopefully raise the profile and leverage of the Board, and enable  public access. Robert Francis’s comments focus on enduring tensions in regulation knowledge and method suggest a rethink of present regulatory expertise.