1. Responding to the Francis Report
Putting Patients First
Hello everyone my name is
You might ask yourself what is Clinical Governance
Clinical governance is an umbrella term for making sure the quality of the services provided continuously improves, standards are met and the environment is safe, the best care is delivered and patients experience is positive.
And also making sure we don’t have a Mid Staff type healthcare in Wandsworth
I’ve been asked to give you an overview from the Francis report and to tell you briefly as to how the CCG is responding to the report
Evonne Harding
Head of Clinical Governance/Lead Nurse
11th September 2013

2. Background & Timeline
Mid Staffordshire NHS Foundation Trust:
manages two hospitals: Stafford Hospital & Cannock Chase Hospital 
provides healthcare for people in Stafford, Cannock, Rugeley and the surrounding areas,
serving a local population of over 276,500 people.
Appalling long term failure and suffering of many patients (2005 – 2009): HCC investigation brought scandal to light, high mortality rates among patients 
Whistleblowing not acted on: Royal College Surgeons say dysfunctional surgical department
Financial recovery = staff cuts
FT: financial focus rather than quality
New Government announced new public inquiry, chaired by Robert Francis QC
2004
2005/2006
2007
2008
2009
2010
2013
CHI 3 stars to zero stars
Final Report published
Full scale investigation
I thought before I tell you about how the CCG is responding to the Francis report, you might find it helpful for me to start with some background information on Mid Staff hospitals
Is in the West Midlands
Patients suffered appallingly between the period of and
Right through there were multiple warning signs which were not spotted or acted on
Commission for Health Improvement which ceased from 2004
Peer Reviews raised concerns about cancer & children’s services
HCC raised concerns re children’s services
Auditors reports identified deficiencies in risk management systems,
Staff & Patient surveys – worst 20% in country
Andrew Burham announced further independent inquiry

3. What went wrong? Organisational
Staffing Issues
Voice of People
Lack of Care
Data issues
Systems issues
Board issues
Staffing:
Poor standards of care
Consultants not at forefront of change
finance over availability of skilled nursing,
Poor leadership and lack of training and support
Voice of people:
No culture of listening to patients:
Inadequate complaints management (resources did not match need)
No effective voice for people
PPI Forums, LiNks , LA scrutiny committee were ineffective
Lack of Care
Compassion and humanity did not exist
Inadequate care of the elderly and vulnerable
Data Quality:
Information not shared and inadequate action taken
Lack of action on mortality figures
Figures preferred to people
Systems issues
The system was poor and failed to protect patients
There were no checks and balances
Focus on systems not outcomes
Board Issues:
Accepted poor standards and didn’t want to hear bad news
Failures to tackle insidious negative culture that tolerated poor standards (disengagement from managerial and leadership responsibilities
Negative culture (“Kiss up, Kick down”),
Report was not overly critical
collective responsibility for failures
Focus on national targets, being and FT and achieving financial balance and forgot what they were in the business of doing which is to care for patients

4. What went wrong 2? Other Agencies
Many Agencies failed to protect patients
PCT/SHA/Monitor issues
HCC/CQC
Local MPs & GPs
Professional Regulation (RCN, NMC, GMC)
Others: Department of Health, Deanery/universities, HPA
Plethora of agencies who should have detected something wrong and did not
If they did detect something, they were ineffective in their action, especially when it was known the Trust was failing
False reassurance from external assessments
PCTs/SHAs/Monitor:
Have a responsibility to monitor & improve quality, had tools to agree safety and quality standards, monitor & pursue remedies
How become FT with all these concerns; did not share information with CHC
too many re-organisations
lack of clarity on responsibilities around quality & safety
Failure to communicate , or share knowledge of concerns between each other
Assumed monitoring, performance management or intervention was the responsibility of someone else
Healthcare Commission/Care Quality Commission:
Reliance on self assessment but no evidence
Not open transparent but appears unhappy and top down closed approach
Local MPs & GPs:
Failed to speak up
only expressed concern after HCC announced it was to investigate.
Professional Regulation (RCN, NMC, GMC):
Weak professional voice
Ineffective as professional representative and as a trade union
Not doing enough to support its members who were trying to raise concerns
Department of Health:
should have acted sooner
did not involve it’s very experience clinical leaders
Accepted disconnect between policy and practice
Deanery/universities:
insufficient importance placed on clinical training in a safe environment
threats to remove trainees largely theoretical, superficial examination of standards use trainees as eyes and ears in a hospital setting
HPA :
did not escalate concerns about HCAIs

5. Overarching Recommendations Themes
Fundamental culture & standards of behaviour change:
Responsibility for, & effectiveness
Patient, Public Involvement & Engagement and Local Scrutiny
Nursing & Medical (training and education)
Openness, Transparency and Candour
Effective complaints and incidents handling
Commissioning for Quality
Joint Working & Leadership
Information
5 Immediate Pledges
Immediate review by NHS Medical Director into 5 hospitals with high mortality rates*(Sir Bruce Keogh’s Overview Report)
New role created of Chief Inspector of Hospitals
Don Berwick brought in to make zero harm a reality in the NHS (Berwick Review into Patient Safety)
Take advice on how hospitals should manage complaints
Trust boards could be suspended for quality failures as well as losing control of the money
We must all remain vigilant to ensure that patients are never again subjected to such poor quality of care.
Fundamental culture & standards of behaviour change:
Putting people at the centre; first and foremost
Common culture & values made real throughout the system
Everyone Counts: commitments in planning guidance
Responsibility for, & effectiveness:
Regulating healthcare systems governance : Monitor, Governors’ role enhance, CQC, simplify regulation, focus on quality
Board of Directors accountability
Patient, Public Involvement & Engagement and Local Scrutiny
Healthwatch & CCG joint working
Nursing & Medical (training and education):
Compassion and Care: in practice; hands on training
Caring for the elderly: registered older person nurse established
Professional regulation of fitness to practice: NMC revalidation
Nurse on each Executive Board
Openness, Transparency and Candour:
Enable concerns to be raised freely without fear
Share true info about performance & outcomes with staff, patients, the public and regulators.
If any patient harmed, they are informed and an appropriate remedy offered, regardless if complaints made or not
Effective complaints and incidents handling:
The learning
Coroners and inquests
Commissioning for Quality
Focus on Quality: shaped by first Francis Report
Fundamental standards set, monitored and enforced
Quality accounts – common form and published, signed by all directors as true, Independent audit
Joint Working & Leadership:
NQB, DH, NHS, LA Leadership Academy in shaping new culture
Enhancement of the role of supportive agencies
No more re-organization without full risk assessment and public debate
Information:
Mortality*
Collection and Analysis : triangulate, feeds into QSGs

6. Wandsworth CCG’s Mission Statement
Better Care and a Healthier Future for Wandsworth
Patient Focused
Involving & Engaging patients
Supporting and Empowering them
Outcomes Driven
Improvements in quality & range of services provided
Commission based on patient safety, clinical effectiveness, patient experience
local & national strategic priorities
Principled
Uphold NHS Consitution
Honesty & Integrity
Thoughtful & Transparent
Responsible
Collaborative
Co-operation with members
Collaboration with partner organisations
Co-ordinated and patient centred care
Progressive & Professional
Responsible to our employees
Respect & value diversity
Encourage innovation and experiment with new ways
Celebrate successes
I thought in telling you how we plan on responding to the Francis report, the key message is the WCCG’ mission statement
We are not starting from scratch and have a reasonably high degree of assurance about services currently commissioned and Iain in his presentation will
The CCG stands for and is driven and commitment to quality

7. CCG’s Framework for Action Approach
Clinicians at the heart of commissioning: system addressing what matters most for patients
Quality Strategy: definition of quality, values based commissioning, quality alert systems:
Quality Assurance Framework: 4 stage methodology
Reflect & Gap Analysis against Francis recommendations
Partnership working with NTDA, LA, Healthwatch, NHSE, CQC
National Quality Reports discussed at IGC: Keogh, Berwick
Duty of candour proposal being discussed at IGC
Engage in South London Quality Surveillance Group meetings
Stage 1:
Quality Programmes
Patients’ having access to information they want to make choices
Healthwatch strengthening their collective voice: close working with the CCG, patient feedback
Real-time to improve quality and timeliness of insight into patient experience (FFT, Enter & View, Commissioner walkabouts, etc)
Publish our Francis Framework for Action to demonstrate our acceptance of the recommendations & our intentions
Stage 2:
Patient & Public Engagement