Addressing Francis

IN September the Royal College of Physicians of London published its full response to the Francis inquiry into failings at the Mid Staffordshire NHS Foundation Trust. Perhaps no organisation has more to say in the wake of the inquiry than the RCP, with many of its members and fellows certain to be directly involved in any reform of hospital services in England. One key figure in formulating the RCP response was the College’s president, Sir Richard Thompson.

Sir Richard has been in that post since 2010 and prior to that was the RCP treasurer. He trained in natural sciences and medicine at Oxford and St Thomas’ Hospital Medical School, and worked as physician and gastroenterologist at St Thomas’ Hospital until his retirement in 2005. He also ran an active clinical research laboratory for over 30 years.

How has the RCP contributed to the Francis inquiry?
The Royal College of Physicians was a core participant and attended the inquiry almost every day. We gave detailed written evidence, and the RCP’s Registrar, Dr Patrick Cadigan, also gave oral evidence.

On 3 September the RCP launched a 35-page response, detailing the actions the RCP will take in future to address the concerns of the final report of the inquiry. The actions cover standards, education and training, commissioning and information. We also included challenges to other stakeholders that are crucial to raising quality in the NHS.

Also, as a result of our close involvement, the need to address the concerns raised by the inquiry has been a touchstone in developing our other health policies over the past two years, and was one of the reasons I decided to set up an independent Future Hospital Commission in March 2012 to improve the care of medical patients. Its report, Future Hospital: Caring for medical patients, was published on 12 September and its recommendations place the patient experience back into the heart of healthcare.

The Francis report highlighted failures of leadership and a ‘lack of ownership’ in dealing with problems at all levels. How can this best be addressed on the ward?
The RCP believes that more and better clinical leadership is the key to adopting a culture throughout the NHS that delivers high-quality care for patients. All doctors are leaders; they all manage patient care, and registrars and consultants manage clinical teams.

The RCP already does a great deal to develop leadership competencies among doctors, via the Joint Royal Colleges of Physicians Training Board (JRCPTB), which works to ensure that leadership is part of doctors’ curricula, and in partnership with the Academy of Medical Royal Colleges to ensure that elements of leadership are part of the curriculum for physicians. We also run a number of medical leadership training and education programmes for both senior and junior doctors. These include an MSc in Medical Leadership, specific programmes for educational supervisors and programmes directed at senior trainees.

The RCP supports the concept of a single responsible clinician for each patient. In future, we shall improve the emphasis on leadership within doctors’ training and continue to work to engage doctors in leadership training above and beyond what they learn in their curricula. We shall also seek to ensure that leadership competencies are developed around the needs of the vulnerable, including older patients.

Do you think there is a need for a statutory duty of candour?
The RCP supports the principles of a duty of candour, which doctors already have as part of the requirements of their registration with the GMC. The RCP recommends that patients and carers should receive an explanation or an apology from the responsible doctor early on in the complaints process, which would help to avoid litigation in most cases. In fact, the RCP recommends there being two patients and an elected doctor on trust boards, who would be responsible for ensuring that the board are aware of, and address, concerns. The RCP is working with the government and other relevant stakeholders on the development and implementation of the duty of candour policy.

How can the problems highlighted in the Francis report be addressed by training and realigning the specialist mix?
The RCP is currently reviewing doctors’ education and training to ensure that it will continue to meet patients’ needs as they change in the future, such as those due to demographic changes. Indeed, many of the problems identified by Francis relate to the care of frail older people – a rising population in hospitals.

More physicians need to train in (general) internal medicine to be able to manage the growing number of patients with multiple long-term conditions; to do this, the specialty needs to be more attractive to trainees. Doctors dealing with acutely sick patients need to have a broad knowledge base from which to practise, for otherwise they may admit more people to hospital ‘just to be safe’. While this is often appropriate behaviour, it has undesirable and unintended consequences both for bed occupancy, costs and exposure to the risks of being in hospital.

The RCP believes that doctors should be trained to lead on holistic care, including taking responsibility for aspects such as compassion, dignity, pain relief, hydration and nutrition. More (general) internal medicine experience in different settings may help to deliver this.

An RCP survey reported that 28 per cent of consultant physicians rated their hospital’s ability to deliver continuity of care as poor or very poor. How best to address this problem?
The publication Future Hospital: Caring for medical patients recommends that care should be organised to maximise the continuity of care provided by the individual consultant physician and key members of the clinical team, with staff rotas organised to deliver this. Once assessed in hospital, patients should not move beds unless their clinical needs demand it. When a patient is cared for by a new team or in a new setting, arrangements for transferring care (through handover) will be prioritised by staff supported by direct contact between staff, and information captured in the electronic patient record. Physicians will provide continuity not only during the hospital admission, but also embed this into follow-up consultations and arrangements.

How are the demands of patients changing?
Patients admitted as emergencies are particularly likely to be older and have two or three co-morbidities, which makes their care more complicated. Patients and their families are also rightly more critical of poor care or a poor experience for themselves or their relatives.

How do you think the NHS could better ensure dignity and patient-centred care among hospital staff?
There should be a named consultant responsible for the care delivered to each patient, every day, who should work with a ward manager and assume joint responsibility for ensuring that basic standards of care are being delivered, and that patients are treated with respect, compassion, kindness and dignity.

What do you see as the key challenges facing NHS hospital care now and in the future?
As set out powerfully in our 2012 report Hospitals on the edge?, our hospitals are struggling to cope with the challenge of an ageing population and increasing hospital admissions. The report described the systematic failure to deliver coordinated, patient-centred care, with patients forced to move between beds, teams and care settings with little communication or information sharing. The NHS struggles to deliver high-quality services across seven days, particularly at weekends, and there is a looming crisis in the medical workforce, with consultants and medical registrars under increasing pressure, and difficulties recruiting to posts and training schemes that involve general medicine.

Add to that the imperative to reduce NHS funding overall, and it is obvious that we need the kind of radical change envisioned by the Future Hospital Commission.

Interview by Jim Killgore, editor of Summons