Learning from the Francis Inquiries

Until last May, I worked at the Department of Health on responding to the Mid Staffordshire NHS Foundation Trust Public Inquiry and blogged (not quite as often as I intended to) about that experience here. It was an intense and emotional role – I would encourage anyone reading this to remind themselves of some of the devastating individual stories in the second volume of Francis’ first inquiry.

I worked with a wonderful, committed team who I know will have been working flat out behind the scenes on today’s publication of the progress report on Hard Truths alongside the findings of, and initial response to, Sir Robert Francis’ Freedom to Speak up Review.

Creating open, learning cultures

The over-riding lessons of the experience for me were that cultures can and do change through good leadership that places the quality triumvirate – experience, safety and effectiveness – at the heart of person-centred care. Leadership that supports NHS staff with the right training, strong teamwork, and safe spaces to reflect, not only on when things go wrong but when they go well.

I saw this change through visits to organisations discussing their actions to implement the Inquiry recommendations, including several week-long ‘Connecting’ placements. I saw it in discussions with inspirational people trying to make a difference, and in the shifting debates about health and care in the press and, vibrantly, across social media. Creating open, learning cultures is not easy, particularly in a service under great pressure, but it is steadily and powerfully resetting the dials on professionalism and involving people as partners in their care.


This interest in professionalism lay behind my move to the General Medical Council. This might seem strange to those who know it only for its powers to remove doctors from practice. Readers may be less familiar with the variety of ways in which the GMC works to promote professionalism and good standards of practice.

This includes determining the outcomes for medical education and training and a programme of quality visits to check whether education providers are meeting standards and to probe concerns raised through the National Training Surveys. It includes a huge swathe of work through the network of responsible officers to ensure doctors are revalidated every five years, and the work of the regional liaison service in delivering workshops with students and doctors.

Patient Safety Concerns raised by Doctors in National Training Survey

The GMC probes concerns raised in the National Training Survey.

And of course it involves the work I have been mostly involved in, which looks at the question of what it means to be a good doctor. This work may seem simple – Mid Staffs certainly had many clear lessons about what doctors should not do – but in practice it is profoundly complex, as eloquently captured by Atul Gawande in his examination of medical performance, Better:

The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others’ and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.

‘How one does such work well’, within our current systems and society, is a dilemma doctors face day in day out. We produce ethical guidance and toolkits to support doctors, including resources to support better care for older people and our learning disabilities website. Our core guide, Good Medical Practice, sets out what the GMC expects from doctors, and is illustrated through the case studies in Good Medical Practice in Action.

We expand on this with detailed guidance booklets on consent, confidentiality, 0-18 years, protecting children and young people, end of life care, leadership and management, and raising and acting on concerns and explanatory guidance on prescribing [PDF], conflicts of interest [PDF], social media [PDF] and much more besides (see the A to Z of ethical guidance).

In nursing and midwifery, there has been a strong focus on the ‘6 Cs’ – care, compassion, courage, communication, competence, and commitment, all core to good medical practice. Later this month, we’re involved in a webinar as part of NHS England’s experience of care week of action on what the 6 Cs mean for doctors and we would be really interested in your thoughts.

Next month’s GMC conference explores the theme of creating a culture of openness, safety, and compassion. We have had a huge response from medical students and doctors in training to our call for posters about the patient safety projects they have been involved in. We will be running workshops to showcase what medical schools are doing to teach the next generation of doctors about their role in making care safer and understanding that healthcare is a safety critical system where understanding human factors and how to prevent harm is key.

Speaking up for safety

Key to a safer NHS is ensuring all staff feel safe to speak up where they have concerns. Two years ago we set up a confidential helpline for doctors who are worried about patient safety and our decision tool guides doctors through the process of raising a concern. We’re currently reviewing all the responses to our joint consultation on duty of candour [PDF] with the Nursing and Midwifery Council and will issue final guidance next month.


We have also commissioned Sir Anthony Hooper to carry out an independent review into how we deal with doctors who raise concerns in the public interest, which will be completed shortly and published on our website.

One of the areas I was most proud to be involved in supporting while at DH was the expansion of Schwartz Rounds, which provide a facilitated safe space in which staff from all disciplines can reflect on the emotional aspects of their work. Research shows this has a positive impact on individuals, teams, patient outcomes and organisational culture.
104 organisations have now signed up to run Rounds – a four-fold increase in under two years. Rounds – and other tools for reflective practice – can help healthcare staff manage the very human and troubling nature of their work.

Atul Gawande, in reflecting on the complexity of performance in medicine, highlights the moral nature of doctor’s decisions and omissions, the daunting expectations doctors face and the uncertainties they face in seeking to “enable every human being to lead a life as long and free of frailty as science will allow” and to “do our work humanely, with gentleness and concern.”

Our guidance seeks to help doctors navigate the morality, expectations and uncertainty, with consistency and concern. I’d love to hear your reflections on what more you’d like to see us doing.

Sir Robert Francis sometimes (unnervingly) cites in talks my DH blog on my own patient experience (brilliant and dire, almost simultaneously) as an example of the shifting culture in DH. It is strange not to be part of DH today, and I’d like to reassure him – and all the many others I worked alongside and learned from – that I am still very much a part of that same journey.

Mary Agnew


Mary Agnew is Assistant Director of Standards and Guidance at the General Medical Council

One response to “Learning from the Francis Inquiries

  1. I think the GMC is trying to run with the hare and hunt with the hounds. Atul Gawande has eloquently stated the medical predicament but it is not a new observation. The GMC can support drs or it can act as the agent of a society which insists on accountability and punishment. The forthcoming conference is an attempt to carry out the former in the knowledge that such an approach has the best evidence for effectiveness. However the actions of the GMC as regulator are not consistent with this. I appreciate that it has to be responsive to public and political pressure but, to take one of many recent examples, when it gets involved with some junior dr’s unwise decision to self prescribe a few diazepam it can hardly be seen as supportive.
    The change of strap line was highly significant. The GMC was signalling that it was in authority and the head teacher cannot then expect to be able to sit and discuss concerns freely in the common room

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