Francis Report 2010/ 2013
Robert Francis QC was asked to chair a public inquiry examining concerns that there had been an excessively high death rate within the patients being treated by the Mid Staffordshire NHS Foundation Trust during the period January 2005 and March 2009.
Francis produced two reports: the first in 2010 (18 Recommendations) and the second in 2013 comprising nominally 290 recommendations.
I have deconstructed each of the Francis 2010 recommendations in accordance with my analytical framework (Part 1). This analysis can be found in the table below.
I have categorised the 2010 recommendations (Part2a) and this can be found in the first column in the table below.
I have annotated my Perfect World systems models (Part 2b) to see where he focused. This can be found here. The reason my number of recommendations does not tally with the total given by Francis is that I have broken down some of his recommendations that had multiple parts into separate recommendations. It is clear form the distribution of the recommendations this work mainly identified where further reviews were required. The Report only produced 7 actions directly designed to improve the system.
2010 Analysis Part 1 and 2a
2010 Analysis Part 2b
2013 Analysis Part 1
My analysis of the Francis Report 2013 (see the table below) recommendations shows the many forms they can take. A few fit my framework as they state: (1) who needs to act, (2) the imperative with which they should act, (3) what action they need to take, (4) on what they need to act, (5) what output their act should produce (and how it should be measured) and (6) what real world effect this change should make (and how this can be judged). The others offer what appears to be a random selection of these criteria where those entrusted to enact these recommendations have to draw implications from their history and the future in order to create a logical narrative that will satisfy the intent. However we have to note that every time an assumption about the requirement has to be made, there is a probability that there will be variance from the original item.
In terms of methodology, this exercise reinforced the following points.
Converting all recommendations into an active format helps to clarify their intent and their gaps.
In any system the output of one subsystem will form the input to another. This means those recommendations that need interpretation have to look for words that might be taken to be either a targeted structure to be transformed, an output, its metric or the outcome. Here I will use recommendation 1.d. as my example. Its states:
(d.) The House of Commons Select Committee on Health should (1) be invited (2) to consider (3) incorporating into (4) its reviews of the performance of organisations accountable to Parliament (5) a review of the decisions and actions they have taken with regard to the recommendations in this report.
Depending on which action (1 to 5) is taken to be the purpose of the recommendation, then what wording matched what criteria is open for debate. This ambiguity must be recognised and must form part of any future debate. I believe that, rather than being a weakness, this framework helps clarify and facilitates the debates.
All acts come with a history and a future. If we again use the recommendation set out above and take the action being recommended as being '(4) review', it is preceded by '(2) consider' and '(3) incorporate' and followed by '(5) review'. How this chain of events is interpreted will affect how the framework is applied to the recommendation. Again we see the framework as being a way to structure this debate.
It is clear Francis' intent is to improve (perfect) the system under review.
He has identified errors and gaps and looks to remedy them. This manifests itself in the number of recommendations produced. Francis stated that he produced just under 300 recommendations: I would say it was many more. Within a number of his recommendations he proposed multiple changes each requiring a deliberate act (I have annotated these as (a.), (b.), (c.) etc.). In this way, I have extracted a further 58 recommendations from his text. It should be noted that this does not even consider the implied tasks associated with each change proposed. One of the assumptions of this research (which needs to be checked) is that a few well focused recommendations are likely to have a more beneficial effect than a large number loosely connected. My proposition is that there is a better way to formulate recommendations by looking at a sub-system in its entirety and articulating how the system should perform rather than just listing individual fixes.
Each recommendation will come with its own list of implicit tasks. These are implied by the way the recommendation is framed. For example, each recommendation will have to be enacted by a person or a team. The work needed to allocate these tasks is implicit within the recommendations. The amount of work implied will however vary greatly depending on how the recommendation is framed. In a number of his recommendations, Francis allocated the responsibility to act on an inanimate object. One example is Recommendation 44 that suggests that a "serious incident … triggers" or Recommendation 161 that asks "training visits (to) make a contribution". The clear implication of these recommendations is that the task will actually fall back on some unspecified actor. To identify this actor will be a task in itself. Where an organisation has been given a task, it will need to be allocated to a subgroup (or team). Within that team there will still be the need to give the task to one person as the lead. A further assumption of this research (which again needs to be checked) is that any lack of specificity in a set of recommendations will add to the burden of enacting them.
The Francis recommendations are multi layered (see my cube concept). If we consider tiering the system into three layers, we have a number of options. One option might be for the top level (macro) to be those directed towards Government Departments: the next layer (mezzo) might be those directed towards hospital trusts and their equivalents: and finally (micro), are those that have the purpose of changing the actions of individuals. [Alternatively macro could be for those recommendations that affect the system as a whole, mezzo are those that affect organisational structures within the system and micro affect individual actions.] There is however, no acknowledgement in the report that the Francis recommendations are mixed in this way. This mixing of layers is grossly misleading over the network of interactions required to implement them. This will add to the complexity of implementing them. Another assumption of this research (which again will need to be checked) is that a failure to recognise the interdependencies between recommendations will add to the burden of enacting them and may also create unintended consequences.
2013 - Part 1 & 2a Analysis
2013 Part 2b Analysis
As I was deconstructing the over 300 recommendations, some issues with categorisation became clearer. When I originally did this exercise, I looked to categorise each according to that part of the system it hoped to change. However I found that I had set myself a surprisingly difficult task as this was not always clear. Looking at the table above, it is now clearer to me why I found it so hard. On reflection, I now know that what I was subconsciously looking to identify the part needing change: to put it another way, what was to be transformed. However, what is now clear from the table detailing my Part 1 analysis of the Francis 2013 recommendations, was that what needed transformation was not always clear. Sometimes a recommendation did focus on the transformation process. In others however, the recommendation only articulated the output or the outcome required from implementing the recommendation.
Within the categorisation process there is therefore quite a lot of interpretation required. This may lead to inconsistencies in the way individual analysts categorise individual recommendations. While, from an academic point of view, this might be seen as being a weakness in the process, from a practical point of view it is not when we remember the overall purpose of the exercise.
No change programme of this scale will be carried out by an individual. It will always involve teams. These teams will (hopefully) have a collection of views from which they need to develop a cross-understanding of the problem. I see this analysis as providing the baseline for that discussion.
One last comment I will make is on the likelihood of such problems 'never happening again'. While Francis may have been attempting to perfect an imperfect system, he is extremely unlikely to meet this expectation. Even if all his recommendations were implemented as designed (in itself a highly unlikely outcome), he has still left at least 48 gaps. These can be seen in the issues that needed further reviews. This reinforces my proposition that if the ideal is to be practical, it cannot be perfection; Normal Chaos will persist and so my continuing quest to identify how we can manage these conditions more effectively. Inquiries that attempt to perfect our systems are therefore doomed to fail.
Part 3 Analysis
What I would like to do is to leave this assessment to be done as a case study undertaken as part of a practical training programme.
Last updated: 3 Dec 21