The Francis Report and poor quality care

Roy Lilley has argued:

Francis talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have have stood still.


“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

A nurse was quoted on… wait for it….the ‘One Show’ saying that she came in on her day off to feed a patient, another story was that two male nurses laughed at a half naked elderly man with a catheter. Two ends of the same care story that is the NHS. There is a problem with attitude/culture but there is a problem with structure (e.g. poor staffing) which gives rise to poor culture. Cultures arise out of structures, they do not just appear out of nothing. The way people relate to each is influenced by so many variables but in an organisation set up with a purpose in mind, those variables start to filter down into the structures that are in place to fulfill the stated purpose. If the purpose is to diagnose and treat a minor illness in an otherwise healthy person, the structures you need are relatively straight forward. The structure of staffing: A doctor or suitable qualified nurse with enough time to take a history, carry out an examination, come up with a diagnosis and then initiate treatment. The structure of place: A clean, well lit, warm private space. The structure of resources: for example assessment tools, stethoscopes, sphygmomanometer, examination table….  These are the foundations to encourage a culture of respect and co-operation. Of course having the structure in place does not guarantee a patient centered culture. The reverse is true, take away the GPs structures and you will more than likely get a little less respect and quality care.

The emphasis on culture and NHS leadership has let society off the hook because we then don’t talk about structures. No doubt the culture and leadership in some Hospitals must change…in addition society has to accept that care work costs money. We just don’t seem willing to put in the extra resources to ensure that the vulnerable are not abused. Feminists have long argued that because patriarchal societies view ‘care work = women’s work’ and women’s work has been seen as ‘domestic’ and unskilled (i.e. required very little training because it is ‘natural’ to women) , care work receives little recogniton and value and sinks into invisibility. The structures to support care work in the UK and in many ‘advanced societies’ are creaking to breaking point, relying on armies of unpaid and unsupported family members.

The analogy is with motherhood and the structures that support it: unpaid, hard work, no training, no sick pay, little support…many mothers go the extra mile every single day, some crack under the strain and abuse or neglect. A minority of mothers abuse because they know no better, they are ill or have given up caring. Any care work that is not properly valued recognised and supported runs the risk of increasing the ratio of abuser to saints. Just as mothers need all the support they can get from society, so do nurses. If you isolate, divide, and undervalue their work do not be surprised when there is an increase in neglect. Society ascribes value to work through pay, status and perks….and so you can get an idea of what society values by examining who gets the pay, status and perks. Capitalism has long divided ‘proper’ work (men’s work) in the public sphere which it has paid for on the one hand, and ‘non’ work (female work) in the private sphere, i.e. the home, which it is unwilling to pay for, on the other. Socialists and feminists arguments have tried to get this private sphere work as being properly recognised in the patriarchal hiearchy and so we have child benefit etc. Historically, if men were nurses, and care work the preserve of men, this would have elevated its status and hence support, education and pay. Roy Lilley is calling for funding the front line, to support the structures of care. Watch however how we turn ourselves inside out trying to correct cultures.






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