Cultural change in the NHS is at the heart of the Government’s initial response to Francis ("the Initial Response"). Francis recommends that "All who work to provide patient care, from porters and cleaners to the Secretary of State, work effectively in partnership in a positive and common culture (Robert Francis 2013, Executive Summary, paragraph 1.120). Accordingly the Initial Response is that cultural change will need to be extended to all staff and not just front line doctors and nurses.
Jeremy Hunt, the Secretary of State for Health, in his Foreword to the Initial Response refers to what he calls "A toxic culture" at Stafford Hospital which, he says "was allowed to develop unchecked which fostered the normalisation of cruelty and the victimisation of those brave enough to speak up."
There are, of course, well established links between patient care and staff engagement. Professors West and Dawson conclude, in a paper commissioned by the King’s Fund in 2012, "that cultures of engagement, positivity, caring, compassion and respect for all – staff, patients and the public – provide the ideal environment within which to care for the health of the nation. When we care for staff, they can fulfil their calling of providing outstanding professional care for patients."
Jeremy Hunt also states in his Foreword that "…we know that those organisations that treat their staff well provide better care for patients."
Recent developments to promote cultural change include a vision and strategy for nursing, midwifery and care staff, which includes the 6 Cs of care, compassion, competence, communication, courage and commitment and encouraging staff to report safety concerns as early as possible (see the Speaking Up Charter).
Set out below are some of the key recommendations in the Initial Response which impact upon staffing issues.
Consultation on a national barring list for unfit managers
Robert Francis identified the need to ensure that, for the small number of managers who let down their patients, their staff and the NHS, there is a mechanism in place which prevents unsuitable managers from moving to senior positions elsewhere in the system.
The Government’s Initial Response is to propose a national barring list for those whose conduct or competence makes them unsuitable for such vital roles, with such a mechanism being under-pinned with a universally adopted code of conduct. But that begs a number of questions not least, who will decide what conduct or competence failures are significant enough to give rise to the need to bar someone, and what procedures will apply in determining barring? It is often the case at present that capability and conduct processes are not followed for senior managers and directors. Jon Restell, Chief Executive of Managers in Partnership has commented that "For most of our members, particularly at a very senior level, when something’s gone wrong process is thrown out the window and they are either sacked or asked to resign."
If the proposed barring list is to be credible it will need to be underpinned by robust, fair and reasonable disciplinary and capability processes for all staff including senior managers and directors. Decisions which may blight or even end someone’s career must be evidence based and operationally justifiable.
Talented leaders fast track programme and training programme for clinical leaders
There is a desire to promote better senior leadership through the NHS Leadership Academy as well as investing in MBA style programmes to ensure that clinicians with a talent for leadership are supported in becoming the clinical Chief Executives of tomorrow. There is also a proposal of a fast track programme to attract highly experienced senior leaders from other sectors.
Ensuring staff are trained and motivated
The Initial Response proposes a pilot programme where NHS-funded student nurses spend up to a year working on the frontline as healthcare assistants, as a pre-condition for receiving funding for their degree. This proposal has been controversial and has been roundly rejected by the RCN. This proposal goes beyond the recommendations of Robert Francis which were for student nurses to satisfactorily complete a three month placement as a healthcare support worker or equivalent, before being allowed to start work as a nurse. It is difficult to envisage this proposal going ahead in its current form.
No regulation for Care Assistants
With the publication of the Initial Response, standards of conduct and training for care assistants were published with no proposal to regulate this large section of the healthcare workforce. There are however various work programmes to be developed to improve recruiting, training, support and progression for healthcare assistants.
The Chief Inspector of Hospitals will assure, as part of inspections, that all hospitals are meeting their legal obligations to ensure that unsuitable healthcare assistants are barred from future patient care by properly and consistently applying the Home Office’s barring regime.
Revalidation for nurses
The Initial Response proposes that the NMC should set standards for appraisal in advance of a revalidation scheme. The purpose of the revalidation scheme is to ensure that practicing nurses are up to date and fit to practise.
Ban on clauses intended to prevent public interest disclosures
Guidance has now been updated making it clear that compromise agreements must include an explicit statement stating that nothing in the agreement prevents the parties from making a public interest disclosure. Any existing confidentiality clauses which purport to prevent a public interest disclosure are likely to be unenforceable in any event. It is acknowledged that there is a place for the use of confidentiality clauses in compromise agreements to ensure the ending of an employment relationship with a clean break. However, it is now clear that any confidentiality clauses must not go further than is necessary to protect matters such as patient confidentiality and commercial interest. Compromise agreement routinely include so-called ‘no bad-mouthing’ clauses, but these are essentially a form of confidentiality agreement and their inclusion now needs to be carefully considered.
The challenge thrown at the door of all NHS employers is how to deliver staff engagement and improve quality of care at a time of growing demand and the need to make financial savings.