Moving engagement and governance on from Francis

stronger voiceThis is our view about what the Francis Report should have said about patient and public involvement and governance, but didn’t.  Mr Francis could and should have gone further.   We support the general thrust of Francis, but we are concerned that what the report says about involvement/engagement with service users and carers in particular is not strong enough.

It is clearly right to stress, as he did at great length, that patients must always be put first and be at the heart of everything the NHS does.  It would be a big step forward in many places if that happened consistently.  But on its own that will not solve the problems in a dysfunctional system, which lie deeper than just poor patient care.

So here are our ideas about how to build on Francis and move the whole users and public engagement initiative forward in the context of better governance – which is where it belongs:

1.  Go much further and invest in lay/patient leadership development.  The reason Francis didn’t explore this is probably a function of the passivity and unequal status relationships inherent in the use of “patient language” he and most other people still use.  Francis’ recommendations are all about good things being done to and for patients.  Rightly so.  But for real service improvement and the creation of responsive organisations, patients and their carers and families have to be equal and powerful partners, not just recipients.  Their leaders have to be on the inside of the health care business too.

Francis doesn’t really understand “outsiders” like patient leaders working on the “inside”.  That’s a dimension to engagement that has to happen, just as there  must be a statutory “duty of candour.”  For the latter to have full impact, there must be a strong, well-informed and well-supported network of lay and patient leaders on the inside of every NHS and care organisation to take this and other relevant information and see that it is acted on.  This should be in addition to anything else that happens through regulators, management and professional bodies.

Put simply, patients and carers need their “own team” batting for them, no matter how friendly other groups may be.  Patient leadership is an investment opportunity, once the NHS understands how to work with users, carers and communities on an “asset” basis rather than seeing us as “costs”.

Post-Francis the NHS has to understand that talking about “patient leaders” is more than just about opportunities and roles – it’s about the attributes of patient leadership and the qualities people need to work with others and promote dialogue.  Putting all that together is about a particular approach to learning and development. It emphatically isn’t about sticking a few patients on committees around the organisation.   The people who know about how to do this right are the Centre for Patient Leadership. Every part of the NHS should be talking to them.

2. Substantially revamp the role of NEDs on NHS Boards. If any one group is particularly culpable it is all the Board and all its members, particularly the NEDs, at the Mid Staffordshire Hospital Foundation Trust. Collectively they “failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.”  Board members must not shut themselves off from what is happening.  These did with disastrous consequences.

To avoid this in future, NEDs  in particular must understand their governance responsibilities vis a vis the “moral owners” of the NHS (that’s all of us who use it and pay for it) and act accordingly in our interests.  NEDs  – and that includes the non-executive Board Chair – are not part of management. They must not “look up” but always “look out”.

That does not mean they have to have some spurious representational role because that would  end up devaluing their contribution to a successful healthcare business. But it does mean that, collectively, they should ensure that the Board as a whole focuses on the quality of the user and carer experience just as much as it focuses on safety and clinical outcomes.

Poor patient experience must be a “Board fail” just as much as poor clinical outcomes are and the risks of getting it wrong need to be taken every bit as seriously as everything else on the risk register.  The NEDs must be plugged in to the patient engagement systems of their organisation so that they are part of the flow of user-led intelligence which is essential to good clinical governance.

3.  Foundation Trust Governors need more power.  Francis recommends some  useful improvements, but still leaves them underpowered for the task they face.  Elected FT Governors, including staff governors, must have a big share in the governance of FTs as integrated healthcare businesses which are increasingly reaching out far beyond the hospital gates into community services and even primary care.

Governors need an independent, elected chair, not the same person who chairs the FT Board.  They need enter and view powers throughout the Foundation Trust for which they have a responsibility.  They might do some visits with members of Local Health Watch.   Governors need regular access to the whole Trust Board, far more than just around the strategic planning cycle, plus a meaningful system of accountability to the Members of the Foundation Trust.

4.  Local Health Watch must be stronger and collaborative.  Frankly the more Local Health Watch works like the best of the late, lamented Community Health Councils (CHCs) the better.  But this must be without encouraging confrontation or adversarial attitudes to its work.  Healthwatch locally must have real clout and be a power on the Health and Wellbeing Boards.  It should be part of front line engagement and be a smart organisation drawing its robustness not from trying to do everything itself but from finding out and synthesising what other local bodies  know about user and carer experiences across health and social care.

Local Healthwatch does not need to be a complaints handler or advocacy service, but it must have a regular and reliable flow of complaints-related intelligence from services which are carrying out those roles and from bodies complained about.  And it must speak with a strong and authoritative voice and be listened to by the HWB, local authority and health commissioners (CCGs and local arms of the Commissioning Board).  Opportunities should be maximised to work collaboratively with FT Governors and lay members and NEDs from FT and CCG Boards.

 Others think this too 

It’s encouraging that National Voices seems to think along the same lines.  Jeremy Taylor’s “Francis in 5 minutes” for HSJ also believes it doesn’t go far enough for patients:

…. we are disappointed that he has pulled his punches on strengthening patient and citizen voice in health. The failings at mid Staffs were as much as anything to do with weak and fragmented citizen voice, and a failure of listening. It is good that Francis wants the role of Foundation Trust governors strengthened. But we hoped to see something more substantial about the role of Healthwatch and about the potential of patient and citizen leadership more generally.

We hoped to see a detailed understanding and response to patient and service user experience beyond complaints. Francis’ conception of involvement is an old fashioned consultative model, with lay people on the outside shouting in. We hoped to hear about patients, families and citizens as co-producers of decisions about their own health and about local services.

Stronger Voices must have Listening Ears

So what is to be done? The simple answer is all of us who think along these lines need to make our collective voices as strong and clear as possible about what now needs to happen to strengthen the “outsiders on the inside” aspect of the reforms recommended by the Francis enquiry.

We look to organisations such as National Voices to do this nationally.  A lot of what needs to be done is already laid out in NV’s Not the Francis Report (October 2012).   And we look to the National Commissioning Board and all NHS bodies to have acutely trained “listening ears” to hear, understand and respond appropriately to what is being said with our “stronger voices.”

Taken together we think this is a good way to approach change in our essential health and social care services  – “from the inside out” –  building on their greatest assets: namely the people who use them and the people who deliver them.

The Millar Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  Feel free to contact us to discuss the opportunities.  Follow MAC on Twitter @publicinvolve



  1. says

    Good points. The biggest challenge is to democratise the NHS so that citizens (patients, public, voters, taxpayers) have an effective voice at all levels and have a direct connection with local councils and parliament: we need to broaden, strengthen and improve our existing democratic mechanisms or they will continue to be bypassed by market mechanisms on the one hand and professional-official structures on the other: both have a role, but they must be subject to democratic oversight and direct. See proposals for a ‘Parliament for Health’ for one suggestion of how this might develop:


  1. […] of that there is no doubt. However until the NHS truly invests in its patient leaders (as stated in this post Francis report summary) this change will never be properly embedded in the service and patients will still be seen as […]

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