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The Francis report: What about drug and alcohol services?

The Francis report into the Mid Staffs NHS Trust dominated the headlines and reignited the debate about health service provision. But what are the likely implications for the substance use sector, asks DDN

Called the ‘worst scandal in the history of the NHS’, the appalling neglect of patients at the Mid Staffordshire NHS Foundation Trust led to a public inquiry chaired by Robert Francis QC and, last month, the publication of his vast and damning report, weighing in at nearly 2,000 pages over three volumes. 

‘There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care,’ wrote Francis to health secretary Jeremy Hunt. ‘For years that did not occur.’ 

His report calls for a system that ‘recognises and applies the values of transparency, honesty and candour’, and contains nearly 300 recommendations that he wants to see ‘all commissioning, service provision, regulatory and ancillary organisations in healthcare’ consider and apply to their work.

But how much are those in the substance misuse sector likely to feel the fall-out from the report? ‘It is largely NHS-focused so if there are services which are run within the NHS then they are going to know about it,’ says social care consultant and DDN contributor David Finney. ‘With, say, the detox services and maybe even any other services that receive NHS funding, there’s probably going to be additional demand on them to make sure they listen to patients or service users. Because the fact that all these families had people who’d received such awful care was the major thrust for getting the Francis report going.’

The last time the CQC was subject to a barrage of criticism – in the wake of the equally shocking Winterbourne View scandal in 2011 – part of its response was to toughen up its inspection regime. Does this mean they’re likely to do so again? ‘I think they will,’ he says. ‘But the only danger is they’ll focus so much on the hospitals that they might stop focusing on the rest of their regulatory function. That’s a possible problem.’ 

One potential outcome, however, is the creation of a more level playing field between NHS services and independent, voluntary services, he explains, as while social care regulation is currently ‘quite robust’ the regulation of the NHS has been more distant – ‘more statistic-based, rather than getting in there and finding out’. 

Responding to the report, the Faculty of Public Health stated that all health professionals must ‘have the confidence to speak out if they are concerned that patient care is being compromised’. The report itself, however, wants to see an enforced ‘duty of candour’, making it an offence for staff not to report their concerns (although in the case of Winterbourne View it was the BBC’s Panorama programme that exposed what was going on, the CQC having ignored the concerns of a senior nurse who contacted them). Is the recommendation practicable, given how whistle blowers tend to be treated by their employers? 

‘That will require a culture change in whatever organisation is being complained about, but if it’s got to the stage of whistle blowing then something’s obviously gone badly wrong,’ says Finney. ‘I hope it works. I hope people realise they’re responsible, because again it’s the lack of a level playing field between NHS services and independent services – the registered manager and the nominated individual are directly accountable and can be convicted of a criminal offence for not doing those things, whereas in the NHS they didn’t have those similar people appointed. So it is really just levelling the playing field and highlighting the fact that it’s got to be done, because the [Mid-Staffs] patients and families are naturally angry that nobody’s been brought to book.’

The report also describes a lack of openness and transparency throughout the system. Is that true on the substance misuse side of things – do those things already exist, or does this need to be worked on more? ‘I think there’s always scope for working on that more, but it is there. But I think this just sharpens the minds of the CQC that they really do have to do that.’ 

The report is fairly damning about the CQC, however – branding it defensive and opaque, among other things. Is that fair? ‘I think it is fair, although that was more in the days of [CQC forerunner] the Healthcare Commission I think,’ he says. ‘I think there is a lack of transparency – a lot of the services I work with aren’t clear about how the CQC are going to go about their business, and sometimes they’re not clear about how they’ve made their judgements, as it’s not immediately obvious. But I don’t think the substance misuse sector has suffered a great deal under the CQC. I’m not picking that up, anyway.’ 

Another focus of the report is around leadership and direction. Having a chief inspector of hospitals, as Francis recommends is ‘an interesting proposal’, says Finney, as it would bring a higher profile to regulation. ‘But the CQC now have this guy David Behan as chief executive, who is excellent – he’s got vision and he’s someone who gets things done. In his past life he used to be a chair of a DAAT in one of the London boroughs, so I think it’s brilliant having him on board. I’m sure he still understands the substance misuse sector and has an empathy for it.’ 

Report of the Mid Staffordshire NHS Foundation Trust public inquiry at www.midstaffspublicinquiry.com