The Government has
accepted all the recommendations of the Independent Inquiry into
Mid Staffordshire NHS Foundation Trust, Health Secretary Andy
Burnham announced today.
The report by Robert Francis QC, published today includes the
patients’ own accounts of the Trust’s appalling failure to provide
basic patient care between 2005 and March 2009.
Responding to the report the Health Secretary set out a package
of measures to ensure the NHS nationally learns the lessons of
this local failure in hospital management and patient care so they
are never repeated. This includes:
· A further inquiry to be chaired by Robert Francis QC, looking
at why the commissioning, regulatory and supervisory bodies did
not detect the failures earlier;
· A new and robust system for senior NHS managers to ensure high
professional standards and prevent failing managers from being
employed elsewhere in the NHS;
· An urgent review by the General Medical Council and Nursing and
Midwifery Council of the evidence in the report and consideration
of whether any action is necessary;
· A dedicated working group led by NHS Medical Director,
Professor Sir Bruce Keogh, to look at the complicated issue of
Hospital Standardised Mortality Ratios (HSMRs) and develop a
single, clearer measure for the NHS and for patients; and
· A call for greater openness and transparency among foundation
trusts with a strong presumption that, where appropriate, Trust
boards should meet in public and governors should have access to papers.
The Health Secretary also confirmed that he has accepted Robert
Francis's recommendation to consider asking Monitor to
de-authorise Mid-Staffs and will ask Monitor to consider this when
the powers come into effect in the coming months. The Health
Secretary will be asking the CQC, Monitor and others for their
views of the trust's long term clinical and financial
prospects, and will consider initiating the process in the light
of their responses.
Andy Burnham said:
“I would like to thank Robert Francis for his thorough report. It
is clear that this hospital failed at every level of the
organisation to ensure patients received the basic care and
compassion they deserve and expect and on behalf of the Government
and the NHS I would like to apologise to the patients and their
families.
“All the evidence confirms this was a local failure, from which
we can learn national lessons. That is why I have today announced
that there will be a second independent inquiry to learn
everything we can about why these failures were not detected
earlier, we will introduce a robust system to monitor performance
of senior managers in the NHS and will work to develop a single
measure of hospital mortality rates. Together with the action we
have already taken over the past year this will ensure we address
every element of this case so that it won’t happen again in the
NHS.
“These events are unacceptable but do not reflect the experience
of millions of patients that use the NHS every day or the
dedication and professionalism of the majority of NHS staff. The
hospital has greatly improved in the last year and I am assured by
the CQC that it is safe to provide services for patients.
“The overwhelming majority of foundation trust hospitals are high
performing, providing patients with the highest quality of care -
but their status is a privilege, not a one-way ticket.
“A foundation trust should not retain its freedoms if it is
clearly failing patients and that is why I introduced new powers
to protect patients and the public - and will not hesitate to
instigate de-authorisation if I believe it is necessary to do so.”
Today’s measures build on a range of actions already taken in the
last year to ensure managers listen to their staff, strengthen the
regulatory bodies and to make the NHS more people-centred. These include:
Arming the Care Quality Commission with tough new powers to
safeguard quality through a new system of registration;Plans to
link up to 10% of hospital income to patient satisfaction;
andIntroducing new powers to allow Monitor to de-authorise
foundation trusts where they are no longer deserving of this
privileged status.
The NHS Constitution reinforces protection of staff who report
wrongdoing and we require every NHS trust to have in place local
policies and procedures to support staff in raising concerns under
the Public Interest Disclosure Act 1998.
NHS Chief Executive Sir David Nicholson has today written to
every NHS Chief and Chair in the country to urge them to reflect
on the findings of this report and discuss the implications for
their organisation with their boards.
Notes to Editors
1. The Mid Staffordshire NHS Foundation Trust Inquiry report by
Robert Francis QC was published on 24 February 2010. The report
can be found at
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018
2. The report makes 18 local and national recommendations. The
key recommendations for the Secretary of State are:
Recommendation 2: the Secretary of State should consider whether
he ought to request Monitor under the provisions of the Health Act
2009 to exercise its power of de-authorisation over the Mid
Staffordshire NHS Foundation Trust. In the event of his deciding
that continuation of FT status is appropriate, the Secretary of
State should keep that decision under review. Recommendation 9: in
light of the findings of this report the Secretary of State and
Monitor should review the arrangements for the training,
appointment, support and accountability of executive and
Non-Executive Directors of NHS Trusts and NHS Foundation Trusts
with a view to creating and enforcing uniform professional
standards for such posts by means of formulated and overseen by an
independent body given powers of disciplinary sanction.
Recommendation 15: in view of the uncertainties surrounding the
use of comparative mortality statistics in assessing hospital
performance and the understanding of the term ‘excess’ deaths, an
independent working group should be set up by the Department of
Health to examine and report on the methodologies in use. It
should make recommendations as to how such mortality statistics
should be collected, analysed and published both to promote public
confidence and understanding of the process, and assist hospitals
to use such statistics as a prompt to examine particular areas of
patient care.Recommendation 16: the Department of Health should
consider instigating an independent examination of the operation
of commissioning, supervisory and regulatory bodies in relation to
their monitoring role at Stafford with the objective of learning
the lessons about how failing hospitals are identified.
3. The Inquiry heard evidence from patients and their families
and from staff at the Trust. 966 individual members of the public
and 82 current and
former members of staff directly or indirectly contacted the
Inquiry. 113 witnesses gave oral evidence to the Inquiry.
4. The Health Secretary set out the Government’s formal response
to the Inquiry Report in an oral statement to Parliament on 24
February 2010.
5. The Department of Health has also published the following
reports which support the NHS in addressing the findings of the inquiry.
Review of Early Warning Systems in the NHS (authors, National
Quality Board) Assuring the quality of NHS senior managers
(authors Ian Dalton, Chief Executive of North East Strategic
Health Authority)The Healthy NHS Board (National Leadership
Council, authors Sue Rubenstein & Adrienne Fresko)
These can be found at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018
6. The HSMR working group led by Sir Bruce Keogh will include key
parties involved in developing and using HSMRs as well as leading
academics and other interested parties for example Dr Foster, the
Academy of Medical Royal Colleges, the Care Quality Commission and
Monitor. All key parties involved in publishing HSMR data have
issued a joint statement on the value of HSMRs. This is available
on the DH website at …..
7. The draft Terms of Reference of the further inquiry by Robert
Francis QC can be found at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018
8. Proposals to introduce de-authorisation powers were announced
in a Written Ministerial Statement to Parliament on 21 July 2009.
http://www.publications.parliament.uk/pa/cm200809/cmhansrd/cm090721/wmstext/90721m0003.htm#09072146000032
9. The powers were introduced through the Health Act 2009 that
received Royal Assent on 12 November 2009 and will come into force
later this year.
10. For further information or a copy of the Health Secretary’s
oral statement to Parliament please contact the Department of
Health Media Centre on 020 7210 5221.
Contacts:
Department of Health
Phone: 020 7210 5221
NDS.DH@coi.gsi.gov.uk