Sir Robert Francis: What Will the NHS Look Like at 100? 

Edna Astbury-Ward


February 19, 2018

MANCHESTER - The judge behind high profile investigations into NHS failings has been telling delegates at the Royal College of Physicians conference in Manchester about his vision for the organisation when it reaches 100 years old.


Sir Robert Francis QC

Sir Robert Francis QC - Chair of Healthwatch England, board member, Care Quality Commission (CQC), and High Court Judge - specialises in medical law, including capacity issues, clinical negligence and professional discipline. He has appeared in a number of high profile healthcare-related inquiries and chaired the Independent Inquiry into the care provided by the Mid Staffordshire NHS Foundation Trust, and subsequently the Mid Staffordshire NHS Foundation Trust Public Inquiry, and the Freedom to Speak Up review.

He spoke to Medscape News UK about his views.


What's your vision for the NHS in the next 30 years?

I will start by pointing out that we need to recognise how far the NHS has come in the 70 years of its existence, and how it is still the most valued part of our society, really, it is. The NHS has produced magnificent changes in the overall health of the country and it is still maintained by its founding principles to be free at the point of delivery and judged according to clinical need. It has faced large numbers of challenges, but despite those it has survived, despite all the travails of 70 years of its existence. If we're looking for what should happen in 30 years' time, obviously we want those same principles to still be in place. Firstly, we need to make sure that we still have the staff that can run the service and provide the service safely. It should have a much higher focus on prevention. So we prevent disease as much as we cure it. We also need to ensure that we have the resources to make sure that can be done.

You said that all too often plans are made in rooms with managers and politicians, and we need to engage with the public more so, 'nothing about them without them'?

Yes, we need to ensure that the public is part of the system in the sense that nothing is done without them. The public are involved in the creation of new schemes, and their needs should be listened to and solutions are found jointly with them, those are the important things. No one would dream of treating an individual patient without first having a conversation with him, a discussion and reaching an agreement with him about what should happen. The same should be applied to discussions about the way in which the public is treated generally, that is happening more than it used to. But it still needs to be a lot more than a tick box exercise. There needs to be different solutions on how to involve the public and patients in these decisions. But the one thing we've got to stop is everything being decided in a room full of people speaking jargon to each other without involving the public.

Looking more broadly beyond our national NHS, I understand that a quarter of the world's top 100 prescription medicines were discovered and developed in the UK, which is brilliant, however, surely the relocation of the European Medicines Agency (EMA) to Amsterdam will adversely impact on that excellence in Research and Development. Do you have a comment about that?

No, I don't think I do, but what I would say is that we managed to regulate medicines before we were part of the EU, we managed to regulate them while we've been in there, you may need to change the arrangements, but I would have thought we have the discipline and the resources available to still do that after we're out.

So, do you still see a collaborative arrangement with the EMA?

How you organise these things is always a matter of debate, but it always is, whatever associations you have, you need to have systems to regulate medicines and we currently have anxieties about online prescribing from abroad to here. So a lot of these things aren't just about how the medicines are made and what they are described as, it's about what you license them for. It's also about who controls the actual provision of medication to the public. So there's a whole range of issues. And we have always been primarily responsible for ensuring the safety of the public here.

The NHS England long-term plan says that it's going to 'ensure properly joined up care at the right time in the optimal care setting'. Could you explain how you see this being achieved?

I think it means that we start thinking about care in terms of the buildings that we have from which to provide it, and actually start thinking where people are and bringing the treatment to them. Other services are brought to where people are very quickly these days, so why can't we do the same?

So do you see investment in communities and community treatment?

That's one thing, but also just plain new style communications will do an awful lot, whether it be through remote treatment through phones or similar devices. We have to cut down the need for people to travel long distances for 5 minute appointments, which could probably be done by another way of communication.

How do you think that vision is going to help elderly people, those who aren't joined up with technology and particularly for people in rural areas?

Firstly, any technical technological solution has to take account of the fact that there are people who won't be able to use those sort of things for a good reason, and therefore, we can't impose those things on everyone. We have to provide the service that people need. Now the younger generation, if one can stereotype it for a moment will be perfectly happy, to be able to have a consultation or blood pressure monitoring over the telephone. That will save a lot of time and resources which can then be devoted to the people who need personal attention. In the good old days, consultants used to go and  visit people in their homes, I would like to see that being something that happened more, because the people had time to do that, because they weren't tied to a desk with a queue of people outside the door coming in to see them.  However, it's putting forward a vision of what might be in existence in 30 or 40 years' time that's important.

Do you know how many of your Mid Staffs report recommendations have been implemented? And do you feel that they have changed delivery of care?

I notoriously made 290 recommendations. If I was to analyse them one by one it would be a wearisome, unnecessary procedure because I have no proprietary interest in the recommendations being implemented to the letter, what I have an interest in still, is that the overall direction of travel of those recommendations meant it has been followed. I think the answer to that is, that it has happened. I believe the system has become much more transparent and open than it was then, not completely, it has a way to go but the duty of candour as a start has made an enormous difference to the attitude people have towards patients generally. I think we hear far more readily about the problems the health service faces than we used to. And so problems about staffing, safety and so on are more readily talked about, and certainly they're more readily exposed. So, in that sense, I think things are moving in the right direction. I think still we won't know for some time how it has changed the outcome.

Your vision for the NHS was about information giving, and indeed, that came out in the Mid Staffs report amongst your 290 recommendations, that communication and information was absolutely crucial. Do you see Healthwatch England as being a part of promoting that?   

The thing about communication is; one is actually allowing people to communicate and encouraging them to do so, whatever the subject is in terms of their health. But the second is listening for what makes that happen when medicine goes wrong with the individual, when doctors or nurses don't listen to what the patient or the parents are saying, it raises the risk of wrong diagnosis. The same applies when you're thinking about changing the system. If you don't listen to people, if you don't test things out with them, then you're likely to come up with the wrong answer. And while I'm absolutely in favour of a drive towards using technological solutions, we can't impose these things on people and it's absolutely vital that we actually address people's needs.

Will they prefer the fallible human to the infallible robot?

Most people prefer the fallible but compassionate, it's got to be a compassionate doctor to the infallible robot.

The NHS long-term plan contains a new online nursing degree. How is that preferential to the current modular university and block placement training? And do you ever see the NHS reverting to the traditional apprenticeship of SRN?

I think the answer is… it depends. There are some forms of online training (not in nursing but in other things), which is ridiculous. You just sit there in front of the screen, but I'm sure that's not what's incentive here. Online learning is now increasingly common in lots of fields, it does enable people to undertake their training in their own time while they have got jobs doing other things, while they're running a family or whatever, in a way [that] you can't if you have to go through a course in a university campus or wherever else.

What was wrong with the old bedside nursing that it can't be implemented today?

The first thing is that I'm really proud of the nursing this country, it's no accident, I'm happy to be patron of the Florence Nightingale Foundation and it's the traditional values of nursing that are as important today as they've ever been. One of the things that went wrong at Mid Staffs I'm afraid, was that because of the pressures imposed on otherwise good people, those values got compromised, but values aren't enough. Medicine has become an increasingly technical business and so has nursing. Nurses now undertake tasks that no one would have conceived when the NHS started and that's good progress, that a wider range of people, possibly some of the most compassionate people our society has, are able and empowered and skilled up to undertake these tasks, so that requires training and I fully believe that it is right that nurses should have training and education to a degree standard….now, how that is provided, it seems to me is a matter of debate. The one thing I'm certain about is that we need to encourage people into nursing from a wide variety of backgrounds. We need a diverse workforce, and we need a diverse means of entry to the profession, but that doesn't, shouldn't mean any lowering of the standards. One thing I said at Mid Staffs and I maintain today is that whatever system you use for training, it is vital that the people have hands on experience and supervision before they are let loose on the public.

Next year, 2020, is the bicentenary of Florence Nightingale's birth. Do you think that the nursing profession still has anything to celebrate?

Absolutely! I think they are the backbone of the National Health Service and healthcare generally. And I think that they have a huge, still have a huge unrealised potential. Their standards, their values, are extremely valued by the public. I just wish that a lot of hospital environments made it much clearer to the patients and others who were the nurses and who were other people but can I just say about nursing, nurses, should be recognised and I think they are in a good place to be recognised as much for being leaders as the doctors. Increasingly medicine is a multidisciplinary game and nurses whether senior or junior have a huge part to play in that. I believe that we would undervalue the voice of nursing and I mean, nursing as well as nurses, at our peril and in that regard, I think there is a way to go in ensuring that the voice of nursing is listened to, is heard.

Overall, do you feel positive that the NHS can be safely steered through the next 30 years?

I'm optimistic it can be, because it is so much part of the DNA of our country and our society, that it will be. No politician stays around very long if they are seen to jeopardise it. Now, that's a boon and also a disadvantage, if it becomes unalterable then it will die, I'm afraid. So, it has to alter with the times and the needs, but I think it's how we change the ability to do that that needs looking at, therefore I'm confident we will be able to do so in the next 30 years as well.


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