‘Francis Task and Finish Group’
Gap Analysis following the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (‘Francis Report 2) Published February 2013
January 2014
This report builds on the Independent Inquiry, published in 2010, following the failings in Mid Staffordshire NHS Foundation Trust between 2005 and 2009.
Patients were failed first and foremost by the Mid Staffordshire hospital but also at a national level by the regulatory and supervisory system which should
have secured the quality and safety of patient care.
The second inquiry was commissioned to help us understand how these failings were allowed to happen by the wider system.
The final report makes 290 recommendations designed to change culture and make sure patients always come first. There are 5 themes outlined in the report:
1.
2.
3.
4.
5.
Clearly understood fundamental standards and measures of compliance
Openness, transparency and candour throughout the system to be enforced
Improved support for compassionate caring and committed nursing
Strong and patient centred healthcare leadership.
Accurate, useful and relevant information
Recommendation
1.
6.

All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations
of this report and decide how to apply them to their own work.

Each such organisation should announce at the earliest practicable time its decision on the extent to which it accepts the recommendations
and what it intends to do to implement those accepted, and thereafter, on a regular basis but not less than once a year, publish in a report
information regarding its progress in relation to its planned actions.
The Governing Body received and approved a paper outlining the CCG adoption of the recommendations in March 2013 as such a
‘Task and Finish sub group’ of the Quality and Risk Committee was convened to ensure the systems and processes were in place to
adopt the recommendations. The group also considered the recommendations from the Keogh Review and Berwick Report.
The Francis sub group undertook a gap analysis against the 290 recommendations of which some were relevant to commissioners and this is presented
below. From this each CCG will develop their own action plan to be monitored through their respective Governing Bodies (GB) via the Quality and Risk
Committee.
Berwick Report: ‘A Promise to Learn-a commitment to act’ Improving the Safety of Patients in England (Aug 2013)
https://www.gov.uk/government/publications/berwick-review-into-patient-safety
The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to
continual learning and improvement of patient care, top to bottom and end to end
KEOGH REVIEW: Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report (Keogh Review), July
2013 http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
As a response to the Francis Report a paper: National Quality Board, How to ensure the right people, with the right skills, are in the right place at the
right time : A guide to nursing, midwifery and core staffing capacity and capability was published in November 2013 (http://www.england.nhs.uk/wpcontent/uploads/2013/11/nqb-how-to-guid.pdf) This outlines the role of commissioners in relation to staffing to:
‘Actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract’.
Commissioners must assure themselves that safe staffing is in place, monitor quality outcomes where staff capacity and capability pose a threat and use
appropriate contractual levers to bring about improvements’.
In November 2013, the Governments final response was published which accepted the majority of the 290 recommendations
(http://francisresponse.dh.gov.uk/) DH (2013) The Government response to the House of Commons Health Committee Third Report of session 201314; After Francis: making a difference. This follows the Governments initial response ‘Putting patients first and foremost’ (March 2013).
The gap analysis below has been updated to reflect the final publications and work to date. Each CCG will develop an action plan and has a nominated
Governing Body member responsible for implementing the CCG specific plan.
The Francis Task and Finish group agreed to group the gap analysis into the following headings (these reflected the commissioning focus):

Patient Voice and Engagement

Commissioner scrutiny and performance

GP effectiveness

Culture and Leadership

Governance
In addition a communication strategy and briefing paper has been developed.
Summary of work to date and the development of an action plan
Clinical Commissioning Groups (CCGs) began the journey of improvement nearly two years ago when they were in shadow form. There has been a
commitment to and focus on improving the quality of services we commission, the accuracy and transparency of data we collect and analyse and the
information we share with others. The gap analysis has identified areas where we need to continue to focus, however our Quality Strategy will ensure we
continue to deliver excellent and high quality services for our local populations.
These areas are:

Further development of the Quality Strategy and framework

Development of the Quality web pages on the CCG intranet

Publicity material for PALS and complaints and ensuring our service is patient focussed and customer friendly

Development of the Patient Experience Team in order to further engage with General Practice to support them to capture patient experience

Development of patient surveys

Development of a Being Open Policy

Development of an Improvement plan following the MaPSaF cultural survey (part of the Quality Survey)

Development of care homes dashboards and transparency of data
In addition to these corporate and strategic actions each CCG will need to assess their patient and public engagement functions, communication
strategies and the way we publish provider data.
Table 1: Gap Analysis
RECOMMENDATION
CCG Analysis
CCG Proposed Action
Date and
Responsible
Person
Action
Complete/Ongo
ing
Jan 2014
Ongoing
Patient Voice and Engagement
Putting the patient first. The patients must be
the first priority in all of what the NHS does.
Within available resources, they must receive
effective services from caring, compassionate
and committed staff, working within a common
culture, and they must be protected from
avoidable harm and any deprivation of their
basic rights
CCG has set out a quality framework and quality
strategy which sets out core values and standards,
detail leadership and assess culture.
CCG business plans/commissioning intentions are
rooted in quality.
The Quality Framework and
Strategy to be further
developed and a process of
engagement with member
practices will begin in January
2014.
Director of
Quality and
Nursing
The NHS Constitution is already embedded in our IPA
Complaints handling processes and PALS service are
pivotal and are often the first contact. It is essential we
deliver a service which is patient focussed. The CCGs
therefore decided to keep these services in house and
to develop further the Patient experience function.
New team in place with new job descriptions to include
patient experience function. This includes engagement
with member practices in order to improve the
reporting/understanding of patient experiences.
Refresh our Complaints/Concerns policy.
Ensure we provide a ‘customer focus’ in our dealings
with patients and carers.
Complete
Web sites to be developed and
publication materials refreshed. Jan 2014
We publish openly and with transparency complaints
data through the quality report at the GB.
Ongoing
Director of
Quality and
Nursing
Complete
The recommendations and standards
CCGs have supported NUH. Pilot underway for a further Draft CQUIN developed and
suggested in the Patients Association’s peer
year. Commissioners have agreed adoption of external with the providers for
review into complaints at the Mid Staffordshire peer review and satisfaction survey CQUIN.
consultation
NHS Foundation Trust should be reviewed and
implemented in the NHS.
Complete
In selecting indicators and means of measuring Patient Reference Groups have been established,
The Patient Experience team
compliance, the principal focus of
People’s Councils and engagements groups established will work with member
commissioners should be on what is reasonably and functioning.
practices in supporting the
necessary to safeguard patients and to ensure
reporting of patient
Engagement strategy in place and includes events such experiences.
that at least fundamental safety and quality
standards are maintained. This requires close as care homes forum etc.
engagement with patients, past, present and
potential, to ensure that their expectations and Patient Stories are presented to the GB.
Jan 2014
Ongoing
Director of
Quality and
Nursing
concerns are addressed
Commissioners should be entitled to intervene The system for managing complaints is set up and
in the management of an individual complaint effective. Good engagement with providers and
on behalf of the patient where it appears to
oversight of their complaints.
them it is not being dealt with satisfactorily,
while respecting the principle that it is the
provider who has primary responsibility to
process and respond to complaints about its
services.
Complete
Complete
Commissioners should be accountable to their Engagement activities and strategies in place.
public for the scope and quality of services they
commission.
Acting on behalf of the public requires their full
involvement and engagement:
Lay and patient representation in commissioning groups
 There should be a membership system such as quality scrutiny panels and quality visits.
whereby eligible members of the public
can be involved in and contribute to
the work of the commissioners.
 Commissioners should create and
consult with patient forums and local
representative groups. Individual
members of the public (whether or not
members) must have access to a
consultative process so their views can
be taken into account.


Patient Experience team to
develop surveys
There should be regular surveys of
patients and the public more generally.
Decision-making processes should be Governing Bodies are held in public. Papers are
transparent: decision-making bodies
published on the web sites.
should hold public meetings.
Commissioners need to create and maintain a CCGs have created web sites, identities and publicised
this through engagement activities etc.
recognisable identity which becomes a familiar
point of reference for the community.
Jan 2014
Ongoing
Director of
Quality and
Nursing
Complete
Berwick 3. Patients and their carers should be
These principles have been adopted for CCGs
present, powerful and involved at all levels of
healthcare organisations from wards to the
boards of Trusts.
Berwick 8. All organisations should seek out
the patient and carer voice as an essential
asset in monitoring the safety and quality of
care.
Achieved through patient stories, PALS and complaints
information, engagement activities and surveys. Lay
membership to GBs and patient representation on
groups, committees and part of provider quality visits.
Complete
Leadership and Culture
Commissioners need to be recognisable public Expertise in house and within CSU (GEM). CCG officers
bodies, visibly acting on behalf of the public
are engaged in local commissioning and understand the
they serve and with a sufficient infrastructure of local population.
technical support. Effective local
commissioning can only work with effective
local monitoring, and that cannot be done
without knowledgeable and skilled local
personnel engaging with an informed public.
Complete
Reporting of incidents of concern relevant to
patient safety, Staff are entitled to receive
feedback in relation to any report they make,
including information about any action taken or
reasons for not acting
CCGs commissioned LISQ programme form NHS
Institute. This provided the level of knowledge for
improvement and patient safety science from which to
build a quality strategy and develop a culture of
continuous improvement.
Complete
Shared learning review group established at CCG level
but not at practice level.
Complete
E-Healthscope issues log has been identified as a
mechanism for capturing concerns and rolled out as a
means to capture feedback.
Complete
The NHS Commissioning Board together with Local Quality Schedules have been developed to
Clinical Commissioning Groups should
include enhanced quality standards for providers.
devise enhanced quality standards designed
to drive improvement in the health service.
Failure to comply with such standards should
be a matter for performance management by
commissioners rather than the regulator,
although the latter should be charged with
enforcing the provision by providers of accurate
information about compliance to the public.
Complete
Methods of registering a comment or complaint CQUIN for complaints management developed in order
must be readily accessible and easily
to improve management of complaints and ensure
understood. Multiple gateways need to be
learning from complaints is embedded.
provided to patients, both during their treatment
and after its conclusion, although all such
methods should trigger a uniform process,
generally led by the provider trust.
Complete
Berwick 1 The NHS should continually and
forever reduce patient harm by embracing
wholeheartedly an ethic of learning.
Berwick 6. The NHS should become a learning
organisation. Its leaders should create and
NHS Institute LISQ programme completed. GBs have
support the capability for learning, and therefore received development on Patient Safety. Shared
change, at scale, within the NHS.
learning group established to share learning widely.
Berwick 7. Transparency should be complete,
timely and unequivocal. All data on quality and
safety, whether assembled by government,
Quality metrics have been developed and are presented
organisations, or professional societies, should
at GB and through early warning dashboards to the
be shared in a timely fashion with all parties
Quality and Risk Committee. These are freely available.
who want it, including, in accessible form, with
the public.
Complete
Complete
Governance
Sharing of intelligence between regulators
needs to go further than sharing of existing
concerns identified as risks.
It should extend to all intelligence which when
pieced together with that possessed by partner
organisations may raise the level of concern.
Work should be done on a template of the sort
of information each organisation would find
helpful.
Berwick 9. Supervisory and regulatory systems
should be simple and clear. They should avoid
diffusion of responsibility. They should be
respectful of the goodwill and sound intention of
the vast majority of staff. All incentives should
point in the same direction.
Quality Surveillance groups at area team level and
region exist. Area team assurance checkpoints and
arrangements between regulators and commissioners re
data sharing in place.
Information schedules in place. Agreement for
cooperation across CCGs through informal and formal
mechanisms such as Collaborative commissioning MoU.
Complete
The NHS Commissioning Board and local
commissioners should develop and oversee a
code of practice for managing organisational
transitions, to ensure the information conveyed
is both candid and comprehensive. This code
should cover both transitions between
commissioners, for example as new clinical
commissioning groups are formed, and
guidance for commissioners on what they
should expect to see in any organisational
transitions amongst their providers.
Handover documents in place, mobilisation boards and
framework for transition in place. Commissioners have
processes in place to manage the transition of services
during re-procurement.
Complete
Commissioners must have access to the wide
range of experience and resources necessary
to undertake a highly complex and technical
task, including specialist clinical advice and
procurement expertise. When groups are too
small to acquire such support, they should
collaborate with others to do so.
This is procured from CSU and through consulting
agencies when required.
Complete
Commissioners need, wherever possible, to
Memorandum of understanding reviewed and refreshed.
identify and make available alternative sources Clinical Commissioning Congress has been developed
of provision. This may mean that
where all CCGs come together to discuss
commissioning has to be undertaken on behalf commissioning arrangements and way forward.
of consortia of commissioning groups to provide
the negotiating weight necessary to achieve a
negotiating balance of power with providers.
Complete
Commissioners must have the capacity to
Teams have been reviewed and where necessary
monitor the performance of every
increased capacity. Shared resources provide resilience.
commissioning contract on a continuing basis
during the contract period:
 Such monitoring may include requiring
quality information generated by the Governing Body members are clear about their roles
provider.
and responsibilities in response to duty to quality.
 Commissioners must also have the
capacity to undertake their own (or
independent) audits, inspections, and
investigations. These should, where
appropriate, include investigation of
individual cases and reviews of groups Quality and performance metrics have been developed
of cases.
and presented into an integrated report to GB.
 The possession of accurate, relevant,
and useable information from which
In addition an early warning dashboard for quality has
the safety and quality of a service can
been developed.
be ascertained is the vital key to
effective commissioning, as it is to
effective regulation.
Complete
CQC essential/fundamental standards and compliance
with NICE guidance occurs through the quality scrutiny
panels.
Monitoring needs to embrace both compliance
with the fundamental standards (CQC) and with
any enhanced standards (NICE) adopted. In the
case of the latter, they will be the only source of
monitoring, leaving the healthcare regulator to
focus on fundamental standards.
Every healthcare organisation and everyone
All public reports are accurate up-to-date. GB Meetings
working for them must be honest, open and
are held in public.
truthful in all their dealings with patients and the
Conflicts of interest policy in place.
public, and organisational and personal
interests must never be allowed to outweigh the
duty to be honest, open and truthful.
Complete
Complete
Gagging clauses” or non-disparagement
HR functions in CSU
clauses should be prohibited in the policies and
contracts of all healthcare organisations,
regulators and commissioners; insofar as they
seek, or appear, to limit bona fide disclosure in
relation to public interest issues of patient safety
and care.
Guidance and policies should be reviewed to
ensure that they will lead to compliance with
Being Open, the guidance published by the
National Patient Safety Agency
All policies to conform to ‘being open’. Serious incident Being Open policy in
and complaints policy compliant.
development
Jan 2014
Director of
Quality and
Nursing
ongoing
A statutory obligation should be imposed to
observe a duty of candour:
 On healthcare providers who believe This is monitored through the NHS standard contract.
or suspect that treatment or care
Evidenced through provider serious incidents and
provided by it to a patient has caused complaints.
death or serious injury to a patient to
inform that patient or other duly
authorised person as soon as is
practicable of that fact and thereafter
to provide such information and
explanation as the patient reasonably
may request.
Complete
The Governments Final response ‘After Francis:
The Standard NHS contract has a duty of candour
making a difference’ has emphasises the
clause, this is to be strengthened in the 14/15 contract
accountability of commissioners as enforcers, a
guidance. Commissioners therefore need robust
failure of the provider must not result in the
mechanisms for ensuring the provider adheres to the
failure of the commissioner to enforce
principles of a duty to candour.
appropriate sanctions.
The duty of candour also applies to
commissioners through the requirement to
publish provider information.
A duty of candour applies to organisations and
to professionals. The latter through their
professional codes of conduct.
The New Care Bill places a duty of candour
on care homes.
Limited information (due to commercial sensitivity)
regarding care homes is published in the quality report
to Governing Body
Berwick 2. All leaders concerned with NHS
healthcare – political, regulatory, governance,
executive, clinical and advocacy – should place
quality of care in general, and patient safety in
particular, at the top of their priorities for
investment, inquiry, improvement, regular
Quality report on every GB agenda.
reporting, encouragement and support.
Escalation of concerns regarding provider’s quality
occurs through sub committees, information sharing with
CQC and Local Authority and Quality Surveillance
groups.
Position paper written for
January 14 GB. Discussions
are required to ensure CCGs
publish full and accurate
information about care homes,
currently little information is
held that can be validated as
accurate. Dashboards in
development, Range of audit
tools in development making
data more acceptable.
Jan 14
Director of
Quality and
Nursing
Ongoing
Commissioner scrutiny and performance
Trust Boards should provide, through quality
CCGs review Quality Accounts and write a statement.
accounts, and in a nationally consistent format, This is shared with CCG GB and published verbatim in
full and accurate information about their
the Quality Account. We have negotiated with providers
compliance with each standard which applies to in relation to quality priorities.
them.
Complete
Department of Health/the NHS ensure that
CCG GB members received a development session for
provider organisations publish in
Quality Accounts (delivered May 2013).
Commissioning Board/regulators should their
annual quality accounts information in a
common form to enable comparisons to be
made between organisations, to include a
minimum of prescribed information about their
compliance with fundamental and other
standards, their proposals for the rectification of
any non-compliance and statistics on mortality
and other outcomes. Quality accounts should
be required to contain the observations of
commissioners, overview and scrutiny
committees, and Local Healthwatch.
Those charged with oversight and regulatory
roles in healthcare should monitor media
reports about the organisations for which they
have responsibility.
GEM provide support for communications. Director of
Quality and Nursing has oversight, relationships with
provider ensures commissioner kept informed of media
interest etc.
Commissioners should require access to all
Quarterly reports from providers are received at the
complaints information as and when complaints Quality scrutiny panels.
are made, and should receive complaints and
CQUIN for complaints management from April 2014.
their outcomes on as near a real-time basis as
possible.
Complete
Complete
The commissioner is entitled to and should,
wherever it is possible to do so, apply a
fundamental safety and quality standard in
respect of each item of service it is
commissioning. In relation to each such
standard, it should agree a method of
measuring compliance and redress for noncompliance. Commissioners should consider
whether it would incentivise compliance by
requiring redress for individual patients who
have received substandard service to be
offered by the provider. These must be
consistent with fundamental standards
enforceable by the Care Quality Commission.
Contracts include standards which are applied. Quality
contract allows for local additions.
Complete
In addition to their duties with regard to the
Through contracts and CQUIN
fundamental standards, commissioners should
be enabled to promote improvement by
requiring compliance with enhanced standards
or development towards higher standards. They
can incentivise such improvements either
financially or by other means designed to
enhance the reputation and standing of
clinicians and the organisations for which they
work.
Complete
The NHS Commissioning Board and local
commissioners must be provided with the
infrastructure and the support necessary to
enable a proper scrutiny of its providers’
services, based on sound commissioning
contracts, while ensuring providers remain
responsible and accountable for the services
they provide
Complete
Shared teams reviewed, restructures complete. MoU
reviewed and refreshed.
Commissioners should have powers of
intervention where substandard or unsafe
services are being provided, including requiring
the substitution of staff or other measures
necessary to protect patients from the risk of
harm. In the provision of the commissioned
services, such powers should be aligned with
similar powers of the regulators so that both
commissioners and regulators can act
jointly, but with the proviso that either can
act alone if the other declines to do so. The
powers should include the ability to order a
provider to stop provision of a service.
Care homes: policies developed jointly with the local
authority which have clear escalation procedures. CCGs
work in partnership with CHC in GEM to safeguard
residents in care homes.
Complete
Strategic care homes group established with Local
Authority, CQC and CCGs.
Governance structure in place and disseminated.
Supported by appropriate policies and procedures.
Commissioners should have contingency
Policies demonstrate clear escalation procedures. This
plans with regard to the protection of
has been tested through closure of care homes.
patients from harm, where it is found that they
are at risk from substandard or unsafe services
Complete
The first priority for any organisation charged
Provided through a number of channels including quality
with responsibility for performance management visits, quality scrutiny panels and verification of data,
of a healthcare provider should be ensuring that internal and external audits.
fundamental patient safety and quality
standards are being met. Such an organisation Internal audit gave significant assurance for quality
monitoring (2012).
must require convincing evidence to be
Complete
available before accepting that such standards
Each contract has an information schedule.
are being complied with.
Complete
Commissioning arrangements should require Updated guidance in relation to safe staffing published
the boards of provider organisations to seek
in November 2013. Requires Directors of Nursing to
and record the advice of its nursing director on ensure safe standards of staffing. This is written into the
the impact on the quality of care and patient
quality contract schedule.
safety of any proposed major change to nurse
staffing arrangements or provision facilities, and This is part of the quality metrics of provider contracts
to record whether they accepted or rejected the and regularly reported to quality committees.
advice, in the latter case recording its reasons
Staff surveys are undertaken. OD plans reflect
for doing so.
responses and actions for improvement.
Berwick 5. Mastery of quality and patient safety
sciences and practices should be part of initial MaPSaF safety culture undertaken with Governing
preparation and lifelong education of all health bodies and improvement plan developing under pinned
with NPSA 7 Steps to patient safety.
care professionals, including managers and
executives.
Draft
improvement
plan March
2014
Ongoing
Director of
Quality and
Nursing
The Governments Final response ‘After
Francis: making a difference’ has
emphasises the accountability of
commissioners in relation to monitoring
provider staffing levels.
Provider dashboards have a section on workforce to
include staffing levels/ratios however this has been
difficult to determine and monitor in community settings,
treatment centres and care homes.
The Quality Impact Assessment process for Cost
Improvement Programmes (CIP) scrutinises staffing
metrics for monitoring the effects of the CIP scheme
such as sickness, staff satisfaction, vacancy rates etc.
Baselines for safe staffing
levels to be determined and
dashboards further developed
in particular care homes,
community providers.
March 2014
Director of
Quality and
Nursing
Ongoing
GP Effectiveness
GPs need to undertake a monitoring role on
behalf of their patients who receive acute
hospital and other specialist services. They
should be an independent, professionally
qualified check on the quality of service, in
particular in relation to an assessment of
outcomes. They need to have internal systems
enabling them to be aware of patterns of
concern, so that they do not merely treat each
case on its individual merits. 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 reality. 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 their patients
seriously if they are to be successful
commissioners.
A proactive system for following up patients
shortly after discharge would not only be good
“customer service”, it would probably provide a
wider range of responses and feedback on their
care.
Patient Engagement team has new job description, roles
to facilitate this.
Numerous methods of capturing and escalating
concerns have been developed; e-healthscope issues
log, reviewed by Quality Team, care homes concerns
template and email, PALS service in-house.
Jan 2014
Director of
Quality and
Nursing