This extract has been taken from the The Guardian on 6th February 2013.
The scale of Robert Francis’s report cannot be overestimated – and neither can the magnitude of cultural change it calls for
In answering the question of why hundreds of patients died needlessly at the Mid Staffordshire trust in the years between 2005 and 2008, Robert Francis QC has identified a culprit: the NHS‘s culture, which focused “on doing the system’s business – not that of the patients”.
A sharp legal brain, Francis has in four volumes and almost 2,000 pages cleverly side-stepped the need for a system overhaul to avoid the disastrous failures of those three years.
Instead he focuses on a system reset with better warning signals, criminal penalties for not acting on breaches of fundamental standards and greater accountability of senior managers.
Francis sees the health service during these years as almost akin to a cult of managerial ideology – seeing the glass half-full when in fact it was empty. He says “poor standards” risking patient care were tolerated and there was an “institutional culture” that “ascribed more weight to positive information about service than to information capable of implying cause for concern”.
In short it was the culture that did it.