The public enquiry into the major failings at an NHS hospital is recommending that hospital staff and managers should face prosecution if patients are harmed or killed as a result of poor care.

The £13 million Francis inquiry, named after its chair Robert Francis QC who specialises in the NHS and medical negligence was published this morning, and is the fifth major investigation into the Staffordshire Hospital scandal.

Data showed that there were between 400 and 1,200 more deaths than would have been expected between 2005 and 2008 at the hospital, prompting a series of inquiries.

A 2009 report by the Healthcare Commission and an independent inquiry in 2010, which was also chaired by Mr Francis, both criticised the cost-cutting and target-chasing culture that had developed at the Mid Staffordshire Trust, which ran the hospital.

The reports found that receptionists were left to decide which patients to treat, inexperienced doctors were put in charge of critically ill patients and nurses were not trained how to use vital equipment.

Today’s report focuses on the role NHS managers and the regulator took during this period and was set up by the coalition government in 2010 just weeks after it came to power.

‘Business before patients’

Francis has made 290 recommendations, with notable recommendations including:

•    The merger of the regulation of care into one body - two are currently involved
•    Senior managers to be given a code of conduct and the ability to disqualify them if they are not fit to hold such  positions
•    Hiding information about poor care to become a criminal offence
•    A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes

•    An increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors

In a letter to health secretary Jeremy Hunt accompanying his report, Francis said the causes of the NHS’s failings at Mid Staffs included: “A culture focused on doing the system’s business - not that of patients” and: “too great a degree of tolerance of poor standards and of risk to patients”.

In a scathing indictment of what happened between 2005 and 2008, Francis said: “A system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.

“The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require a root and branch re-organisation – the system has had many of those – but it requires changes which can largely be implemented within the system that has now been created by the new reforms.

“I hope that the recommendations in this report can contribute to that end and put patients where they are entitled to be – the first and foremost consideration of the system and everyone who works in it.”

Speaking ahead of the report earlier today, NHS Confederation chief executive Mike Farrar said: “The culture of that organisation was not geared up to put patients’ needs right at the heart of it; there was almost an institutionalised blindness to what mattered.

“The risk, I think, today, is that we look to external things like better regulation or more inspection, to try to solve what effectively is a problem that can really be only solved by having a culture in every hospital where every member of staff is geared up to try and provide the best possible care for patients.”

A time for change in NHS culture

The overriding political concern is to make sure that another Mid Staffs incident will never happen again – but there are still a number of groups who believe the NHS isn’t learning its lesson.

In November The Patients’ Association released a report based on the negative stories from patients and their carers treated in the NHS, which revealed that some patients were still being failed on a “deeply distressing” level in hospitals and care homes.

Writing in a comment piece for Nursing Times, its editor Jenni Middleton, said that the Francis report “must not be another document that gathers dust on a shelf”. She went on: “It must not be dismissed by health workers. It must not be something that dominates the headlines for a few days before falling into obscurity.

“This must be the catalyst that inspires positive change. Financial targets and scarce resources are not an excuse for people dying needlessly, or suffering pain and indignity. Francis can have a lasting positive effect - but it is up to the government and the entire NHS to make sure it does.”

Major reform

The NHS in England is set to change dramatically in April when a new NHS Commissioning Board will take formal control of the NHS budget, and filter down responsibility to new GP-led Clinical Commissioning Groups, that will commission NHS services in their areas.

These 227 CCGs will replace the soon to be abolished Primary Care Trusts and Strategic Health Authorities set up under the Labour administration in 2006, although many of the managers from these groups are expected to help CCGs with their transition this year.  

Gail Beer, Director at the 2020health think-tank and a former hospital director, said: “We need to remember the events at Mid-Staffs happened during a time of unprecedented growth so how can money have been the issue. Although the Strategic Health Authority and hospital Trust Boards were responsible for making sure care was delivered, the focus was always on money and targets. If you got these right, it seemed it didn’t matter if your outcomes were poor.

“[Prime Minister] David Cameron has already announced a new Chief Inspector of Hospitals, but this feels like adding another layer of bureaucracy instead of dealing with the NHS culture dominated by fear and figures.

“As sector regulators, the [regulators] Care Quality Commission and Monitor need to be totally separate from the NHS so they have the freedom to test and challenge without any political pressure being brought to bear. At the moment only the Health Select Committee seem to have a truly independent voice.”