Unsurprisingly, the publication of the Francis report has led to much reflection among managers, clinical leaders, and health commentators. My (pre-publication) concerns are here, but we won’t get answers for a while, until the government has taken a view on the 290 recommendations contained within the report.
But what about doctors? What are some of the implications for the profession?
Doctors do not emerge from Francis unscathed. Whilst the main deficiencies were in ward-based nursing care, mortality rates were persistently high and doctors failed to raise concerns effectively. Much has been made of the ‘climate of fear’, but I struggle to believe this alone explains why concerns were not raised early, loudly and persistently. After all, there is safety in numbers and many hospital chief executives have lost their jobs over the years as a result of a Consultant Staff Committee vote of ‘no confidence’ – why not at Mid Staffs?
I have argued for a re-wording of the GMC’s Duties of a Doctor to make much more explicit the duty to raise concerns about wider care issues involving patients other than their own, for instance elsewhere on a ward or in a hospital. The second duty ‘Protect and promote the health of patients and the public’ is perhaps too general in this respect?
There are implications for services too, that I have alluded to in my Weekly Diary and which need considering in detail. Essentially, the quality and safety concerns relate to our acute general services, and predominantly medicine. And if we are honest, these have been less glamorous areas of practice, and less invested in, than many of our specialties. Specialists have progressively pulled out of the general on-call rota, knowing that the way to build a career and a reputation is to focus on their work as an ‘-ologist’.
But most of the work of an acute hospital is in ED, acute and ‘general’ medicine, and care of the elderly. If we are to make a step improvement in quality standards, we need to invest a greater proportion of our resource in these areas. More doctors, and maybe more nurses on wards with high acuity?
Such a move will have knock-on effects. I cannot see how to increase resource here without decreasing investment elsewhere. Add in the move to 24/7 acute services, and we have a huge need for new investment. That can only mean spreading the available resource less thinly and reducing the range of services on a particular hospital site?
It can be argued that, anyway, concentrating specialist services on fewer sites leads to better outcomes, with acute stroke or PPCI or cancer services often quoted as examples. But perhaps it needs to go further, with improvement of acute general services as the main driver?
As I see it, I will have to orientate my hospitals more strongly around acute services if I am to rise to the Francis challenge and really improve care quality standards with more staff, more capacity, and more time to care. If this leads to relinquishing some ‘high end’ services then many doctors will be concerned, because building a specialist service portfolio is deeply ingrained in medical culture. It is how progress is judged, and it is often the way by which hospitals are judged when selecting jobs.
If Francis provokes the development of a new world, maybe it will be a world where ED, acute and general medicine, and elderly care medicine, are higher up the unofficial hierarchy – at the top even? Any thoughts?
This blog was written for Hospital Dr and originally posted here on 18 February 2013