1. The Francis Report....... Dr Susan Salt, Medical Director, Trinity Hospice Blackpool

2. Why Senior doctor running a large hospice in the North West of England How we care matters How we enable staff to care day in day out matters How we enable staff to be patient centred is a continual challenge? We fool ourselves if we think it could not possibly happen where we work….

3. Background Between 2005-2008 conditions of poor care were able to “flourish” in the main hospital serving the people of Stafford and its surrounding area In 2009 Robert Francis QC was commissioned to chair a non-statutory inquiry by the Secretary of State for Health In 2010 he was asked to chair a public inquiry

6. What was the problem? Patients were left in excrement in soiled bed clothes for lengthy periods Assistance was not provided with feeding patients who could not eat without help Water was left out of reach Despite persistent requests for help, patients were not assisted with toileting Privacy and dignity even in death were denied Staff treated patients and those close to them with what appeared to be callous indifference

7. Robert Francis QC said about the Trust that.... It had a culture focussed on doing the system’s business – not the patient’s Was an institution that ascribed more weight to positive information about the service than to information implying cause for concern Had too great a degree of tolerance of poor standards and of risk to patients There was a failure of communication between the many agencies to share knowledge of concerns There was an assumption that managing performance was someone else's concern There was a failure to appreciate the risk of disruptive loss of corporate memory and focus resulting from repeated multi-level re-organisation

8. A task….. How do you feel about what you have just heard / read?

9. Overview of the talk Not a new or unique problem Brief overview of the possible causes Challenging our own thinking New model of care Embedding a culture of openness and candour Conclusion

10. NOT NEW OR UNIQUE

11. Some Previous UK Reports Health Service Ombudsman Reports (1995 / 2014) The Alder Hey Inquiry – retention of tissues after death (1999) The Bristol Inquiry – poor paediatric cardiac outcomes (2001) High Quality Care For All (2008) Care not pathway (2013) – care of the dying patient Morecombe Bay Hospitals 2015 – poor maternity care

12. POSSIBLE CAUSES….

13. Suggested causes from the Francis Report... Patients not heard Wrong priorities Negative Culture Professional disengagement Poor governance Lack of focus on standards of care Inadequate risk assessment of staff reduction Nursing standards and performance

14. Who are the people we care for? Anyone with an incurable illness are essentially people on a journey. They are uprooted, dispossessed, marginalised, travelling fearfully into the unknown. The conditions and speed of the journey may vary - the movement may be barely perceptible but at other times it may hurtle through the night throwing the occupants from side to side. Above all they are alone and afraid. Sheila Cassidy - Sharing the Darkness

15. CHALLENGING OUR THINKING

16. What do you see?

18. PRAGMATICS (Intentions) Content SEMANTICS (Meaning) Purpose SEMIOTICS (Signals and codes) Technical rules Attitudes Beliefs Norms National government and National Health Service regulation Regional bodies: e.g. strategic health authority (SHA) Cancer networks Professional requirements / medical speciality qualifications Personal interests Colleagues / multi-disciplinary team members Employing organisation Local community needs Individual patients / clinical situations The complexity involved in seeing one patient.......

19. A task What helps you be compassionate in your work?

20. Why is it so hard…? The professional may not be smart enough, patient enough, imaginative enough; the patient might not be trusting enough, brave enough, receptive enough Rita Charon 2006

21. NEW (OLD) MODEL(S) OF CARE

22. What might influence what you dare to say? Safety Environment Mood / Emotion Energy levels Context Content Knowledge Perceived implications – For me – For those close to me

26. EMBEDDING OPENNESS, TRANSPARENCY AND CANDOUR

27. Openness, transparency and candour A common culture Common values Clear rules Monitoring compliance Enforcement of compliance Accountability Effective handling of complaints and incidents

28. Collective Leadership.. Focus on the delivery of high quality care Enable staff to do their job effectively Value, support front line staff Ensure team work and shared values

29. Collective leadership Patient and carer involvement and voice Expect and value complaints, critical comments Data – relevant to the service and quality of that service LISTEN, LISTEN, LISTEN, LISTEN…..

31. Final Thoughts….. A doctor (person) who recognises the patient in the face of the sickness, who respects the patient’s strength despite the fear, who accompanies the patients through the territory of illness that the doctor knows well, and who honours the meaning of the patient’s suffering provides not just knowledge of diseases but knowledge of the direction toward health or the ability to live authentically without health. (Charon 2006)

33. References Charon R (2006) Narrative Medicine – honouring the stories of illness. Oxford University Press West et al (2014) Developing collective leadership in healthcare. Kings Fund. www.kingsfund.org.uk Steward et al (2014) Exploring CQC’s well led domain. King’s Fund. www.kingsfund.org.uk National Advisory Groupon the safety of Patients in England (2013). A promise to learn – a commitment to ac: improving patient safety of patients in England. Department of health, London. www.gov.uk/government/publications/berwick-review-into-patient-safety https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs- foundation-trust-public-inquiry Searle J (1979) Expression and meaning – studies in the theory of speech acts. Cambridge University Press Silverman J, Kurtz S & Draper J (2005). Skills for communicating with patients. Oxford University Press Enhancing the quality of life for people living with long term conditions – The House of Care www.england.nhs.uk/house-of-care