February 2013 Discussion paper 7 Putting the patient first: issues for HR from the Francis report This discussion paper has been designed to help inform and shape the format of our forthcoming listening workshops for HR directors. The workshops will provide the content of the NHS Employers organisation s response on specific recommendations from the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Robert Francis QC. This response will be submitted to the Department of Health and published on our website. This paper does not attempt to summarise the report and its recommendations, but provides some contextual background to ensure we can retain the focus on why change is required and what is needed. By taking some of the recommendations and working through a set of preliminary questions, it asks for views from the HR community. This will focus on: the NHS Constitution; leadership and accountability of directors; nursing, healthcare assistants and the staff survey. We will be asking your views on: recommendations which should be accepted immediately and which need further working through whether there are any recommendations that will not help to deliver the changes required (the aims of the recommendations are listed in Box 2) whether there are any challenges to, or potential consequences from, implementation potential suggestions or options available to meet any of the recommendations and desired aims. We know the report is calling for cultural change at a time when there are significant financial and employment relations challenges facing employers, coupled with a system that is changing and which needs providers to build new relationships with commissioners of both services and education. These cannot be underestimated. When viewing all of the issues together, the HR community is faced with an enormous organisational development challenge to lead and deliver. As you look at recruitment, appraisal, training, Key issues for HR directors In addition to the specific recommendations, there are three overarching questions for HR we want to explore: how can all organisations ensure they are providing high-quality, safe and dignified care? how can HR help organisations manage the twin challenge of securing financial savings at the same time as improving quality of care? there is a clear emphasis within the report, and in the Government s response, on the links between patient care and staff experience. How can NHS Employers support HR leaders to help deliver this agenda and make change a reality?
development, leadership, management, supervision and performance management, we want to use the workshops as an opportunity to ask what more could we, as your employers organisation, do to support you. The inquiry Robert Francis has been very explicit in stating that all levels of the system failed in keeping patients safe at Mid Staffordshire. Accepting this analysis and ensuring that this does not happen again means it becomes incumbent on us all to reflect upon our own priorities, focus, actions and behaviour and to view the recommendations as a set of actions to be owned by us all. There is a strong message both within the report and in the response from the Government about accountability for implementation. Many commentators have called for all 290 recommendations to be accepted in full. Taking action and ensuring there is pace in implementation are critical, but we must not lose sight of what we are striving to achieve. Box 1: Creating a patient-focused culture throughout the whole system The report identified a number of negative aspects of culture within the system that contributed to the failings at Mid Staffordshire: a lack of openness to criticism a lack of consideration to patients defensiveness looking inwards not outwards secrecy misplaced assumptions about the judgements and actions of others an acceptance of poor standards a failure to put the patient first in everything that is done. To change this, the report suggests that we need a relentless focus on the patient s interests and the obligation to keep patients safe and protected from substandard care. ; and to empower frontline staff with both freedom and responsibility within strong and stable leadership in stable organisations. It lists the following as ways of achieving the right culture: emphasis on a commitment to common values throughout the system by all within it readily accessible fundamental standards and means of compliance no tolerance of non-compliance and the rigorous policing of fundamental standards openness, transparency and candour in all the system s business strong leadership in nursing and professional values strong support for leadership roles a level playing field for accountability information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation. 2
Box 2: Essential aims of the recommendations Foster a common culture shared by all in the service of putting the patient first. Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated. Provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service. Ensure openness, transparency and candour throughout the system about matters of concern. Ensure that the relentless focus of the healthcare regulator is on policing compliance with those standards. Make all those who provide care for patients individuals and organisations properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service. Provide a proper degree of accountability for senior managers and leaders to place all with responsibility for protecting the interests of patients on a level playing field. Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do. Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public and all other stakeholders in the system. Reference: Robert Francis letter to Secretary of State, 5 February 2013. The report states: The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: a common set of core values and standards shared throughout the system leadership at all levels, from the ward to the top of the Department of Health, committed to and capable of involving staff with those values and standards a system which recognises and applies the values of transparency, honesty and candour freely available, useful, reliable and full information on attainment of the values and standards a tool or methodology, such as the cultural barometer, to measure the cultural health of all parts of the system. The 290 recommendations within the report span a whole range of areas. No single one is, on its own, a solution to the concerns highlighted in the report. There is also a risk to 3
think of them purely as actions for individuals or organisations which, if carried out, will mean that we would not see tragedy occur again. This is not the case and we need to keep in the forefront of our minds that it will be our relationships, coupled with process, that will deliver sustained success. Leadership, management and positive engagement with staff and patients, underpinned by systems and processes which support individuals and organisations with making the right decisions for patients, are what will shape a culture of safety and dignity. Government response The Government is considering its initial response to the report and is likely to give a first report in March. The Secretary of State has already stated that he accepts the analysis presented in the report and sees effective leadership, staff engagement and high standards of care as key areas for action by all NHS organisations. Specific areas for discussion The NHS Constitution There are several recommendations that refer to reviewing and amending the NHS Constitution to ensure that it contains and clearly articulates the NHS values and the rights, obligations and expectations of patients. The report suggests using these values in recruitment and appraisal processes and incorporating the requirement to adhere to the NHS Constitution in employment contracts. It also suggests that a duty of openness, transparency and candour be created and the responsibility to be open and transparent be embedded with the NHS Constitution. In addition, there is a recommendation that the NHS Constitution should incorporate reference to all codes of conduct and standards with which staff are expected to comply. As well as new levels of fundamental, enhanced and developmental standards that providers and commissioners will need to develop and ensure delivery against. Key questions: Should the NHS Constitution be amended and if so what does it need to include? What are the challenges and solutions available to us to ensure the NHS Constitution becomes meaningful to staff and patients? How can we ensure it becomes the lever for change as described? Are there other actions needed to build a consistently open and transparent culture? What should we focus on? Leadership and accountability of directors in provider organisations The role of leaders and theme of accountability runs throughout the report. If we accept that the cultural change required throughout the system, it needs leadership at all levels that is both patient focused and responsible. Do the following recommendations within the report set the boundaries in which this can be achieved? Ensuring a programme of training and continuing development is available to directors locally and for a system to be created to provide common professional training and accreditation in healthcare leadership and management. A code of ethics, standards and conduct for board members, and for its use to be enforced by the employer. A list of qualities of effective leaders to be drawn up and used in selection. Create and introduce a fit and proper person test and for provisions to be made for regulatory intervention if a person is found to be no longer meeting the requirements. Serious failure in performance within the role being reported to Monitor, the Care Quality Commission or the National Trust Development Authority. This could include not demonstrating due regard to protecting patients and 4
maintaining confidence in the NHS. Being found in serious breach of a code, as described above, could be an example which triggers the report to the regulator and potential disqualification from director roles in the future. Key questions: Is the balance right of support for board leaders alongside a formal accountability regime? What else might be helpful to ensure we encourage talented individuals to aspire to take on board level roles? Should anything else be included to deliver an open and transparent service? Nursing The report was critical of many aspects of nursing and specifically made recommendations about: creating a responsible officer for nursing in each provider organisation the selection of individuals into training and employment who have the appropriate values, attitudes and behaviour as well as the ability to learn the necessary technical skills the content of training having sufficient focus on compassion and caring student nurses satisfactorily completing a three-month placement as an healthcare assistant (HCA), or equivalent, before being able to start work as a nurse nursing leadership which constantly reinforces values and standards of compassionate care the role of ward managers being supervisory, coordinating, leading role models encouragement for nurses to report concerns and give priority to patient wellbeing the Nursing and Midwifery Council (NMC) to look at setting standards for appraisal as a forerunner to a revalidation scheme to strengthen the nursing voice, the Royal College of Nursing has been asked to consider its dual role as both professional body and trade union, and there is a specific recommendation that employers look at the time granted to local staff representatives to undertake their role recruiting nurses to nonexecutive director positions National Institute for Health and Clinical Excellence including measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. Key questions: Should these recommendations be nursing specific? Is there a need to strengthen the role of the employer in nurse training? What would this look like? How could local appraisal be strengthened and used by both the employer and the regulator to assure a continuing fitness to practise, including a commitment to delivering safe, dignified care? What are the implications of making the ward manager role supervisory and are there training and development needs to consider? Do organisations use the cultural barometer, or an equivalent tool, to help form an assessment of the cultural health of the organisation? How can this be used by boards to best effect? Healthcare assistants There has been much debate in the months preceding the publication of the report around whether or not healthcare assistants (HCAs) should be regulated. The report makes a number of recommendations 5
that have been borne out of the level of confusion from patients, relatives and sometimes staff, around the large number of job titles used, the different uniforms and the lack of visible identification badges. It also recommends the need to have a standardised code of conduct for HCAs and national standards for education and training; and that will lead to the registration of HCAs being required and undertaken by the NMC. Key questions: What are the hurdles to overcome if we are to address the issue of clarity with these roles, for patients? How might we implement a code of conduct and minimum standards for training? What are your views on the feasibility and necessity to register HCAs with a regulatory body? Using the NHS staff survey and engaging patients The staff survey provides a source of data on many of the issues raised by this report, especially staff engagement, staff views on quality of care, on willingness to raise concerns and to recommend the services of the organisation. From April 2013 this information will be linked to data on the views of patients as part of the friends and family test. Key question: What are the actions we need to take if we are to truly put patients first and build meaningful engagement with them? Next steps The views collected from the listening workshops will form NHS Employers response to the key HR-related recommendations. This will be presented to the inquiry response team within the Department of Health and shared with other organisations who have responsibility for taking forward the recommendations within the report. In addition to our role representing you, we want to be able to support you with implementation. We will create further opportunities for discussion and engagement throughout the year. Please contact us if there is anything specific that you would like us, your employers organisation, to be doing on your behalf. We have created a dedicated email account: francis@nhsemployers.org or contact the NHS Employers representative from your HR Director network. 6
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NHS Employers The NHS Employers organisation is the voice of employers in the NHS, supporting them to put patients first. Our vision is to be the authoritative voice of workforce leaders, experts in HR, negotiating fairly to get the best deal for patients. We help employers make sense of current and emerging healthcare issues to ensure that their voice is front and centre of health policy and practice. We keep them up to date with the latest workforce thinking and expert opinion, providing practical advice and information, and generating opportunities to network and share knowledge and best practice. We work with employers in the NHS to reflect their views and act on their behalf in four priority areas: pay and negotiations recruitment and planning the workforce healthy and productive workplaces employment policy and practice. The NHS Employers organisation is part of the NHS Confederation. Contact us For more information on how to become involved in our work, email getinvolved@nhsemployers.org www.nhsemployers.org enquiries@nhsemployers.org NHS Employers 4th Floor 50 Broadway London SW1H 0DB This document is available in pdf format at www.nhsemployers.org/publications Published February 2013. NHS Employers 2013. This document may not be reproduced in whole or in part without permission. The NHS Confederation (Employers) Company Ltd. Registered in England. Company limited by guarantee: number 5252407 Ref: EINF27601 @nhsemployers NHS Employers 2 Brewery Wharf Leeds LS10 1JR www.youtube.com/nhsemployers