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Will the response to Francis really make things better?

If culture can be dictated from Whitehall, then everything in the NHS is going to be perfect. The blizzard of initiatives, new law, and new reporting requirements that Jeremy Hunt, the health secretary, announced today in the formal response to the Francis inquiry into the terrible events at Mid-Staffordshire could scarcely have been more comprehensive.

Including some measures already announced there will be new Ofsted-style ratings of hospitals and new hospital, social care and GP chief inspectors. Hospitals will report monthly, ward by ward and shift by shift on whether they meet minimum staffing levels. There will be a new legal duty of candour on organisations, with a requirement to tell patients about incidents that have led to death or serious injury. A new offence for board members if they misreport data. A new offence for staff of wilful neglect or mistreatment. New independent help for patients to make complaints, with the number of complaints and action taken reported quarterly. A new ‘care certificate’ for health care assistants. The list goes on. The aim, the health secretary said, is to promote “a culture of openness and transparency” within the NHS so that it learns from its mistakes. So powerful is the political demand that something – or in this case many things – must be done to avoid a repetition of what happened at Mid-Staffordshire, that to question whether all this will achieve its aims, or whether some of it might make things worse, is to invite the charge of heartless heresy. But the question has to be asked. As the Francis report made clear, Mid-Staffordshire resulted from a huge cultural failure allied to a distinct failure of regulation. The answer to failed regulation, however, is not necessarily more regulation but making what you have work. On this test, there are some good things in the government’s response. It will introduce a ‘care certificate’ for health care assistants, but not full regulation. It has avoided seeking to regulate managers but has, rightly, introduced a measure that can debar someone as being not a “fit and proper person”. It has rightly rejected a recommendation to merge the Care Quality Commission and Monitor. And, again sensibly, it has decided to get the professional regulators such as the General Medial Council to strengthen its requirements for candour rather than go for a new legal duty. It has rejected the idea of mandatory staffing levels, instead going for guidelines – when a mandatory level would beg the question of what happens to the patients if a hospital falls below a mandated ‘safe’ level of staffing, with mandatory standards anyway likely to ossify innovation in the way care is delivered. So far, so good. But whether many of the other measures will indeed foster a culture of openness and learning – which is what any good organisation, let alone the NHS, needs – or will instead create a climate of fear and reporting is far from clear. Huge weight – probably too much weight – is being put on inspection, regulation and an overall rating of hospitals. A new criminal offence for boards that misreport data, when board members are heavily reliant on staff for that data, may discourage good people from taking on the job. Making a hospital directly liable for negligence claims by removing or limiting its insurance if it has not been candid – as is being considered – is a recipe for penalising other patients; there are no shareholders here. And there will be a measurable cost to assembling and publishing all this new information on ward by ward staffing levels, complaints and their handling – will the cost of that bring about sufficient improvement for the amount of money it takes away from patient care? Which brings us to an issue that was missing from today’s statement. Money, and what will happen both to the government and the NHS as the service heads into its next financial crisis, as it is surely doing, even though the pace of that remains uncertain. Unlike in the past, there will be no hiding place if the finances start significantly to affect performance. Huge amounts of data are now published on waiting times. More is coming on clinical performance. Today’s announcements will increase the recent tendency to highlight the service’s failures, rather than celebrate its successes. How will the public and electorate react? Demand more cash from a coalition government that argues there is none available? Or lose faith in the project? And then be happy to see it replaced – with what?

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