Public inquiries are curious beasts. They move slowly and are very expensive. They are invariably verbose and make multiple recommendations, some of which are more tangible than others. Their true impact should probably only be assessed several years after publication, not several days. The Francis Report is no different.
However, if Robert Francis’ recommendations have been met by a degree of head scratching, then the fault is certainly not all his. There is a reason why eminent lawyers are asked to chair public inquiries and it is fair to say it is not their ability to generate purple prose or compelling top lines for journalists.
It is up to the governments who commission and must respond to such reports to help make sense of them for the public, media and services affected. In this sense, the Government’s early response to Francis has been puzzling.
David Cameron’s response in the House of Commons to the report displayed many of his greatest strengths. Having responded to inquiries into Bloody Sunday, Hillsborough and now Mid Staffordshire, the Prime Minister has displayed a sure hand and voiced the correct tone. On occasions like this, he is now a master at speaking – and apologising – for the nation.
But striking the right tone is only one part of the job. Governments need to pick out the key themes from inquiry reports and explain how they will address them. They need to help those affected by inquiries to make sense of what has occurred, what has been found and what they intend to do about it.
I must admit that I was not expecting the Government to make any policy announcements when it published the report, after having announced a few weeks ago that it would be releasing the report just one day after receiving it. I was fully expecting the Government to take its time and set out a considered response in March. I am not sure when or why the decision was taken to set out some immediate policy changes on publication, but it is clear that the policies announced were designed in some haste. It is less clear that they are part of a coherent narrative about what went wrong or how it should be put right.
First, there is the review of the regulation of healthcare assistants. Such regulation was recommended by Robert Francis, but the very announcement of the review surely means that the Government wants to avoid it or at least has little confidence in its deliverability (why ‘review’ the recommendation otherwise?). But if this is right, then why appoint a review, with a suggestion that Camilla Cavendish – a journalist with a track record of arguing in favour of regulation – will lead it? There is every chance that the review set up to provide the Government with the excuse not to implement the regulation of healthcare assistants will end up again recommending precisely that regulation should occur.
There is also the new, ‘single quality and finance’ failure regime. This would make sense if it meant that the Care Quality Commission had the power to appoint a Trust Special Administrator to make a service subject to repeated and prolonged regulatory action sustainable (in the same way that Monitor will do in the event of financial unsustainability). But the Prime Minister’s statement indicated that such a failure regime would extend only to the suspension of the organisation’s board. That is not a ‘regime’; it is not even ‘new’: that kind of intervention can happen already.
Then there is the planned appointment of a ‘Chief Inspector of Hospitals’ – something which would have been a good idea, two centuries ago. Anyone involved in care will tell you that such an appointment (or appointments) now needs to cover primary and community care, and social care, as well. From what the Health Secretary indicated yesterday, when he hinted at the appointment of further ‘chief inspectors,’ he has fully caught up on the last two centuries in the last one week.
Setting aside whether a hospital focused on hospitals is sensible; it does not fit well with the call for regulatory simplicity. As my colleague Bill Morgan has argued, having overlapping regulators is as much a recipe for omission as it is for duplication. Put simply, if two organisations are both meant to be doing the same job, there is a danger they leave it to each other. The Secretary of State may argue that this is about joining different regimes together but is hard to see how an individual with a big title will make things work better. If regulatory simplicity is one of the key messages of Francis, then responding to it by adding one more piece to an already crowded puzzle does not seem to be sensible.
Nor does this additional role sit well with Jeremy Hunt’s argument that assessments and inspections need to be cut to prevent another scandal like Mid Staffs (at the same time as advocating that the very same regulators who often do the inspections should have been tougher). Although the argument that nurses should be able to focus on patient care will attract some sympathy, what exactly is the Chief Inspector meant to do if it is not inspect?
Finally, there is the review of hospitals with high mortality rates. The NHS has been round the houses on this for some time. There is now – at last – a consensus emerging that such information should be in the public domain and that hospitals should be required to account for their performance. But this information has been known for some time and the announcement poses more questions than it answers. If there is a case for investigating high rates, then why wait for now? If there was a problem, this should have happened months – if not years – ago. If this is about acting to reassure the public, then does it actually achieve this or the opposite? And, in future, will hospitals with higher mortality rates automatically be investigated? And why by the NHS Medical Director and not the Care Quality Commission (or indeed the Chief Inspector of Hospitals)? There is a strong case for commissioners to be more proactive in investigating failure, but – at the same time as making a case for greater simplicity – this has not been explained. The result is more uncertainty and a still more confused narrative.
Of course, being in government is hard – and if the Government had announced no policies when it published the report, there is every chance that I would have instead just criticised the failure of the Government to be seen to be taking action. But the response leaves us none the wiser as to whether the Government wants more regulation of health or less; whether the failure regime can be triggered on the grounds of quality or not; and quite what role mortality rates will play in indentifying quality risks, or who indeed should identify the risk.
All of this means that the public – and the health sector – is left confused. Francis’ focus on culture is important, but it was always going to be difficult to distil into a compelling narrative or a convincing remedy. We must of course wait to see the Government’s full response to assess how it will take forward Francis’ recommendations. Unfortunately the immediate response has made the task of explaining what happened and what needs to change all the more difficult.