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Final response to the Francis Report: What should nurses be looking for?

November 18, 2013

In principle, I don’t have much of a problem with the idea that ‘doctors, nurses and NHS managers will face up to five years in jail if they are found to have wilfully neglected or mistreated patients’ (The Guardian, 15/11/13). Yes, it’s a cheap way to look as if you’re doing something, yes, it’s a bonanza for the lawyers – but essentially all it would do would bring the NHS into line with the 2005 Mental Incapacity Act, under the terms of which persons who neglect or ill-treat adults who lack capacity can be jailed if found guilty. What’s wrong with extending the same protection to all NHS patients? No one argued that the perpetrators of abuse at Winterbourne View (who were prosecuted under the 2005 Act) were treated with undue severity.
What I do have a problem with though, is the fact that the government chose this particular issue to be the one that made all the headlines in the run-up to the publication of their final response to the Francis Report. By ensuring that the news stands and airwaves were filled, in the days preceding the publication of this long-awaited document, with talk of uncaring doctors and wilfully neglectful nurses, the government is again driving a wedge between staff and service users, and even worse, is tacitly encouraging the public in the view that all health care professionals are potential abusers.
If we are looking for a restoration of public trust in the Health Service, things are not, on this latest showing, getting off to a very good start. A far more positive move might have been to trail an area that everyone – service users and health care professionals – can unite around: staffing levels, in other words. The fact that David Cameron seems to have made a conscious decision not to do this is as big a hint as we need that whatever measures are announced on staffing, they will probably fail to meet with the approval of professional organisations. But over and above that, it’s also another manifestation of the highly cynical policy of raising public suspicions around the standard of NHS care: if there is nothing to worry about, people are going to say, why do we need this new law?
To answer that, let’s step back from the front line for a moment, and remember that, according to the headlines at least, any new law will apply to managers as well as the rank-and-file. So one positive might be the potential to protect staff and patients alike from the activities of unscrupulous managers who, in order to save money, cut staffing levels to the bone without giving any consideration to the blindingly obvious fact that safe care cannot be delivered in the conditions they have created.
Earlier this month, the panel in the NMC’s Fitness to Practice hearing on Jan Harry, former Director of Nursing at Stafford Hospital decided that ‘[Her]…failure to ensure adequate staffing levels and skill mixes on a number of wards had placed patients at risk of harm and…in danger. The panel bore in mind that [she] had not placed patients at risk directly, through failings in [her] clinical practice, but indirectly, through…failing to ensure adequate nursing provision at the Trust’ (p32). The message could not be clearer: just because you’re no longer involved in direct care-giving, you’re not absolved of responsibility for its failings.
Any new initiatives on safe staffing must build on this recognition. Work must continue apace to develop staffing algorithms that are robust as well as flexible. Their selection and application must be rigorously policed not just by the CQC but also by Clinical Commissioning groups. We don’t want to be in a situation a few years down the line where managers involved in some new NHS scandal are arguing that they cannot be blamed because all they did was apply the approved staffing tool – even though it was later found to be inappropriate and inadequate.
Integral to the correct operation of staffing tools (and the maintenance of acceptable levels of care generally) is the proper protection of the whistleblower. But it is difficult for these brave individuals to come forward in an ‘us and them’ atmosphere where managers are unapproachable and rarely glimpsed on the shop floor. Although it’s tricky to legislate for it, how good would it feel to see managers walking the wards, reaching out to staff, proactively seeking their views and feeding back on action taken?
What nurses should be looking for from tomorrow’s announcements is a step back from the nurse-bashing (“it’s all because they lack compassion!”) tone of the government’s initial response to Francis towards a more balanced understanding that good care is dependent on the presence of a number of different factors, many of which are not under the control of frontline staff.
In broader terms however, we have to move on from Francis, and in order to do that, we nurses must get a message of our own out to service users: we are on your side; we want what you want. We look to the government for the tools to make that manifest.

For the NMC’s ruling on Jan Harry, see
http://www.nmc-uk.org/Documents/FTPOutcomes/2013/Nov/Ammended%20Reasons%20HARRY%20CCCSH%2026589%2020131107.pdf

For reporting of the proposed new legislation, see:
http://www.theguardian.com/society/2013/nov/16/doctors-face-jail-if-patients-mistreated

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