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Francis 2 – a wasted opportunity

February 17, 2015

By Basket Press

Finally we have the long awaited second Francis Report and what do we make of it?

OK, I’m grateful that it happened at all, as the history of whistle blowing and attempting to raise concerns in the NHS is appallingly bad, as I think we all know. But will Francis make any changes to that? Will this report make any practical difference?

On the positive side, it is in many ways as thorough as you would expect, sets out the relevant legal framework and context, took contributions from a significant number of NHS staff and former staff (disclaimer – I was one of them) and surveyed even more, and highlights that there are some, albeit a very small number, of instances of raising concerns having a good outcome.

But, and it is a very big but, what I find disturbing is the sheer scale of negative experiences documented and the nature of those experiences – figure 3a on p54 shows the level of bullying and victimisation, the lack of support, the counter-allegations made and the cultural issues, which I will return to – and the extremely deleterious effects on people’s health and well-being and finances and careers. In fact chapter 3 makes very scary, and oddly familiar, reading, with the disparity between what staff say and what employers, or even professional bodies, say being as wide as ever. Still, it is a positive that Sir Robert makes all this abundantly clear (see 4.2 for example) and was obviously affected by what he heard and read.

The cultural problems within the NHS (and as highlighted by Andrew Smith in The Guardian in other organisations) are mentioned repeatedly, but I do not feel the true scale and extent of these is acknowledged, while undue emphasis is given to employers’ protestations that things aren’t really that bad and that they are changing. On several occasions (5.2.5 or 5.3.18, for example) Sir Robert refers to existing policies or documents which are supposed to assist and support staff in raising concerns but shies away from considering why and how these appear to be ineffective. The prevalence, and probable increase, in bullying is also highlighted, but again Sir Robert shies away from the uncomfortable truth that ALL NHS organisations already have anti-bullying policies and procedures and does not address either the efficacy of these or their implementation.

Hoary old chestnuts about “leadership” and its “visibility” are trotted out, without really defining what that means, nor acknowledging that current leaders can be part of the problem and that many of us would be glad never to see or hear them because of that and would view increased “visibility” as snooping on the basis of past behaviours.

Suggestions about good habits, such as reflective practice, are what some of us were already doing. However these are often targeted by management as “inefficient” use of time and discouraged or even banned (as happened to the nurses in my old service). The discussion of improving the handling of cases is pretty unarguable, but I still wonder why the suggested best practice isn’t already happening – all that information is out there.

In fact that idea runs through the entire document: good practice is already known and defined; policies, procedures, principles, or whatever you want to call them already exist in all NHS organisations, but Sir Robert repeatedly slides away from addressing why they are not acted upon or why the exact opposite happens or why staff are discouraged from using those practices and policies.

He also avoids the question of why so many people feel it necessary to raise concerns about existing practices and problems and why those problems exist, when, as pointed out above, most of the necessary knowledge is already out there. Suggestions about improving training in investigating concerns raised and the like are all well and good, but this already exists. The problem with all training is the lack of time available for it away from one’s regular duties and the lack of management support or financial resources for any training, including clinical. Avoiding those issues renders the suggestions pretty much useless. It also makes me wonder what exactly it is that managers study when they do their MBAs if all these principles and extra training are so necessary.

The idea of making a non-executive director an “independent voice” is laughable, given the existing complicity of non-exec in current problems and the limited credibility they have.

Arguably Sir Robert compounds this problem by giving us yet another set of “principles” and a nice fluffy “vision” diagram (fig 4a on p91). Now, those “principles” he suggests, and the “vision” diagram, are, again, pretty unarguable and, to be honest, don’t really stretch the bounds of what is already known to be good and sensible practice and behaviour. We are into educating one’s mother’s mother in albumin extraction procedures…

Andrew Smith, in the previously mentioned Guardian piece, describes this report as “toothless”, with some justification I feel. Section 7.5, on accountability, highlights this best as Sir Robert runs away from the idea of regulating managers, choosing to hide behind the Fit and Proper Person Test, which comes nowhere near the level of regulation legally required of clinicians, and applies only to directors. This really misses the point quite spectacularly. It is almost like Sir Robert cannot bring himself to believe that managers do actually, and often very deliberately, behave badly and should answer for that. Without regulation of managers at least as onerous as that of all clinical disciplines, and the consequent ability to finally hold them accountable for their actions and inactions, all these nice fluffy “principles” and the like are hollow and meaningless, unenforceable fripperies, just like many existing policies.

All in all, lots of nice words, no meaningful action. Opportunity missed. Again.

The extent of some of the cultural problems is the topic for another post…

***************************************************************************************

Dear Friends,

Circumstances beyond my control mean I am unable to post here myself this week. I do not know how long this situation will continue. If any readers would like to support the blog and help to keep it going by submitting guest blogs, please contact me via Twitter.

All the best,

Grumbling Appendix

 

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