What the Francis report means for GPs

How will the fallout from Mid Staffordshire affect GPs? Marina Soteriou and Nick Bostock report.

GPs will have a fundamental part to play if the NHS is to avoid repeating failures of care that led to hundreds of avoidable deaths at Mid Staffordshire NHS Foundation Trust.

In his first report on Mid Staffordshire, published in 2010, Robert Francis QC identified a need for a further investigation to discover how the NHS system as a whole had failed to detect and address the trust's inadequacies earlier.

On 6 February, Mr Francis released the findings of the public inquiry set up to undertake this task.

The inquiry found the culture at the trust was too focused on targets, not patients. NHS reorganisations did not help, by erasing 'corporate memory'.

Key points
  • GPs to monitor quality of all care their patients receive.
  • Healthcare professionals and providers face 'duty of candour'.
  • GMC to be more proactive in monitoring fitness to practise.
  • CQC to take over Monitor's regulatory functions and oversee compliance with all standards, governance and financial performance.
  • Services that repeatedly fail to meet required standards must close.

Sharing concerns

Poor standards were tolerated and this was allowed to persist because organisations involved in patient care did not communicate or share knowledge of their concerns. Different organisations and people always felt performance management, monitoring and intervention were someone else's responsibility.

Although the report stresses that no one person or organisation should be singled out, it suggests GPs could have done more at an earlier stage to highlight concerns.

The report calls for a statutory 'duty of candour', requiring registered medical practitioners or providers to report cases in which they believe a patient has been harmed.

For GPs, the recommendation goes far wider. In future, the Francis report says, it will be vital 'that all GPs undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services'.

GPs should be an 'independent, professionally qualified check on the quality of service', with 'internal systems enabling them to be aware of patterns of concern'.

'They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patients' choice a reality,' the report says. 'A GP's duty to a patient does not end on referral to hospital, but is a continuing relationship. They will need to take this continuing partnership with patients seriously if they are to be successful commissioners of services.'

The government's official response to the 290 recommendations in the Francis report is due next month.

But if it takes the recommendations about GPs at face value, how much will the profession's role change?

GPs as advocates

GPC deputy chairman Dr Richard Vautrey says the recommendations simply 'firm up a role GPs have'.

'I think this adds weight to the role GPs should already have as advocates for their patients,' he says.

But Dr Vautrey warns it would be 'foolish' to require GPs to review every patient after a hospital visit. 'We need to empower patients to come to the GP if there is a problem, not place extra burden on GPs,' he says.

RCGP chairwoman Professor Clare Gerada also says that many GPs already recognise their 'obligation to patients once they have been referred'.

Whether legislation is the right way to ensure all GPs act in this way is open to question.

Dr Stephanie Bown, director of policy and communications at the Medical Protection Society (MPS), says you cannot legislate to create a cultural change. She warns: 'It will be a tick-box approach and that defeats the purpose of a culture change - doing it because it is the right thing to do.'

Even if GPs accept the role of advocate, current government policy may make it increasingly difficult for them to fulfil this role.

Under the any qualified provider (AQP) policy, the range of organisations running NHS services is expanding, making it difficult for GPs to remain aware of standards across the board.

BMA deputy chairman and retired GP Dr Kailash Chand says the government needs to abandon its AQP policy if it wants GPs to have a monitoring role.

'That is why you need to put the NHS as the preferred provider,' he says. 'AQP is a fundamentally flawed concept. Monitoring providers is going to be a difficult task for GPs.'

Middlesbrough GP Dr Heather Wetherell says that the changing landscape means GPs will have to listen even harder to patients.

'Our patients make the best informants. Listen, believe, trust. The clues are there,' she says.

Greater integration of services, within the NHS and across health and social care, may help to cut out poor care by protecting individual doctors from isolation and improving communication across organisational boundaries.

Increasing continuity

Professor Gerada says: 'Patients' needs are becoming more complex and federations offer the availability of increased and more specialist services, increasing continuity. Federations also offer much-needed peer support.'

But once GPs identify a problem, who should they tell, particularly if their local hospital board has been unwilling to listen in the past?

Manchester LMC secretary Dr John Hughes argues that only health and wellbeing boards can take on this role in the new-look NHS.

'Health and wellbeing boards are supposed to have an overview of the whole system. The question is whether anything comes as a result of raising concerns,' he says.

The DH should come up with a mechanism for this, he adds. 'It perhaps does have to be an independent body. The CQC and Monitor are going to be overloaded.'

Dr Vautrey, however, feels plenty of channels are already open to GPs who need to raise concerns.

'Most practices will go to the provider directly, speak to the consultant in charge or do it through their LMC,' he says.

For GP commissioners, the emphasis the Francis report places on policies that put patients first and targets - particularly financial - second, could have significant implications for rationing decisions.

GPC negotiator Dr Chaand Nagpaul warns that GPs 'should not be complicit in systems within CCGs that they believe are detrimental to patient care'.

'CCGs need to start off on the right foot', he says. 'GPs should feel empowered. GPs and CCGs need to ensure patient care is managed appropriately, not driven by cost.'

Doctors found to be involved in failings of care could also be subject to tougher regimes in future. Nobody has been struck off, despite the deaths at Mid Staffordshire, and in his initial response to the Francis report, prime minister David Cameron said the GMC would be asked to set out how it would strengthen its 'systems of accountability'.

Feedback from friends and family tests will also be used to put pressure on poor performers.

Mr Cameron said that poor results could trigger the suspension of hospital boards. GP practices may face similar threats when the tests are rolled out to them in the coming years.

Perhaps the greatest test for the government will be to implement Mr Francis' advice when the NHS is driving through £20bn in efficiency savings and undergoing a massive reorganisation. At a time like this, reaffirming GPs' role as patient advocates has never been more important.

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