Improving openness—including candour when things go wrong, and willingness to learn from mistakes—is increasingly seen as a priority in many healthcare systems. This study explores perceptions of openness in England before and after the publication of the Francis report (2013), which examined failings of openness at one English hospital. We examine whether staff and patients’ views on openness, and experiences of giving voice to concerns, have changed since the report’s publication for better or worse.
Organisational-level data was collated for all trusts from the NHS National Staff Survey (2007–2017), NHS Acute Inpatient Survey (2004–2016) and NHS Community Mental Health Service User Survey (2007–2017). Survey items related to openness were identified and longitudinal statistical analysis conducted (piecewise growth curve and interrupted latent growth curve analysis) to determine whether there was evidence of a shift in the rate or direction of change following publication of the Francis report.
For some variables there was a discernible change in trajectory after the publication of the Francis report. Staff survey variables continued to rise after 2013, with a statistically significant increase in rate for “fairness and effectiveness of incident reporting procedures” (from + 0.02 to + 0.06 per year;
Data suggest that the Francis inquiry may have had a positive impact on staff and acute inpatients’ perceptions and experiences of openness in the NHS. However such improvements have not transpired in mental health. How best to create an environment in which patients can discuss their care and raise concerns openly in mental health settings may require further consideration.
The original version of this article was revised: Figure 1,2,3,4 have been revised.
A correction to this article is available online at
corrected publication [2020]
Calls have been made for greater openness within the National Health Service (NHS) in England, with the intention of creating of a culture ‘
The events at Stafford Hospital were tragic and extreme but may not have been unique. Accordingly the Francis inquiry [
The impact these initiatives remains unclear; accordingly a longitudinal research design was applied using data from NHS annual surveys of staff and patients to explore perceptions of openness since the publication of the Francis report (2013) to answer the research question: Are staff and patients’ views on openness and experiences of giving voice to concerns changing through time, for better or worse?
This study used a longitudinal, observational design, examining routinely collected annual data aggregated to the organisational level. Full details for all surveys and years can be found in Table Response rates for NHS Staff and Patient Surveys Survey Year Number of questionnaires sent out* Number of questionnaires returned Response rate Number of Trusts 2007 291,843 157,667 54% 392 2008 289,919 159,691 55% 360 2009 289,277 157,450 54% 387 2010 311,098 167,736 54% 390 2011 250,000 134,967 54% 365 2012 203,188 101,169 50% 259 2013 416,313 203,028 49% 264 2014 603,937 255,150 42% 289 2015 722,811 298,817 41% 296 2016 948,640 414,330 44% 316 2017 1,067,266 478,872 45% 309 2004 142,432 88,308 62% 169 2005 136,937 80,793 59% 164 2006 136,769 80,694 59% 166 2007 135,623 75,949 56% 165 2008 134,415 72,584 54% 165 2009 133,362 69,348 52% 161 2010 132,696 66,348 50% 161 2011 133,704 70,863 53% 161 2012 126,480 64,505 51% 156 2013 127,435 62,443 49% 156 2014 125,709 59,083 47% 154 2015 176,843 83,116 47% 149 2016 176,932 77,850 44% 149 2007 41,842 15,900 38% 69 2008 41,014 14,355 35% 68 2009 n/a n/a n/a n/a 2010 53,746 17,199 32% 66 2011 52,852 17,441 33% 65 2012 49,619 15,878 32% 61 2013 46,552 13,655 29% 57 2014 46,552 13,500 29% 57 2015 41,650 11,695 29% 52 2016 49,300 13,254 28% 58 2017 47,600 12,139 26% 58
The NHS Acute Inpatient Survey (‘Inpatient Survey’) is conducted each year within acute care. The survey collects patients’ views about their stay in hospital [
Data from the NHS Community Mental Health Service User Survey (‘Mental Health Survey’) was sourced for years for 2007–2017 (excluding 2009 as no survey was conducted that year). The survey collects patients’ views about the care they received whilst using mental health services [
The Francis report called for improvements in “openness, transparency and candour,” defined respectively as
“the proactive provision of information about performance, negative as well as positive” (openness), “the provision of facilities for all interested persons and organisations to see the information they need properly to meet their own legitimate needs in assessing the performance of a provider in the provision of services” (transparency), and “the volunteering of all relevant information to persons who have, or may have, been harmed by the provision of services, whether or not the information has been requested” (candour) [
We sought to operationalise these values by choosing items from the three surveys that related most closely to them. A list of questions from each survey that had remained consistent over a minimum of 6 years, including the period from 2011 to 2014, was compiled. These were then examined individually by five members of the research team (including the three authors of this article, one medical sociologist, and one other health services researcher). Each was assessed for whether it was strongly related, moderately related, or not strongly related to any of the three definitions of openness, transparency and candour above. Where questions were identified by all as being strongly related, they were chosen for the analysis. Where they were identified by some as being strongly related, but by others as being only moderately related, these were discussed by the research team and agreement reached about whether they should be included. All members of the research team approved the list of items before analysis began. Analysis included all trusts that had remained single organisations over the period. The final set of variables included is shown in Table Details of questions used in study Survey Variable Original question & scoring Aggregation method Good communication between managers and staff Four questions with 5-point Likert-scale responses (ranging from “Strongly disagree” to “Strongly agree”): • Senior managers here try to involve staff in important decisions. • Communication between senior management and staff is effective. • I know who the senior managers are here. • Senior managers act on staff feedback. % employees who agreed or strongly agreed with at least three of the four statements Can contribute towards improvements Three questions with 5-point Likert-scale responses (ranging from “Strongly disagree” to “Strongly agree”): • There are frequent opportunities for me to show initiative in my role. • I am able to make suggestions to improve the work of my team / department. • I am able to make improvements happen in my area of work. % employees who agreed or strongly agreed with at least two of the three statements Fairness and effectiveness of incident reporting procedures Seven questions with 5-point Likert-scale responses (ranging from “Strongly disagree” to “Strongly agree”): • My organisation treats staff who are involved in an error, near miss or incident fairly. • My organisation encourages us to report errors, near misses or incidents. • My organisation treats reports of errors, near misses or incidents confidentially. • My organisation blames or punishes people who are involved in errors, near misses or incidents. • When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again. • We are informed about errors, near misses and incidents that happen in the organisation. • We are given feedback about changes made in response to reported errors, near misses and incidents. Average scale score calculated for each individual (based on 1 = “Strongly disagree” to 5 = “Strongly agree”); these then averaged across all individuals in each organisation. Information about condition or treatment A single question, with wording “While you were in the A&E Department, how much information about your condition or treatment was given to you?” Responses “The right amount” (scored as 100), “Too much” or “Too little” (scored as 50), or “I was not given any information” (scored as 0) Scores averaged across all respondents for the organisation Involvement in decisions about care and treatment A single question, with wording “Were you involved as much as you wanted to be in decisions about your care and treatment?” Responses “Yes, definitely” (scored 100), “Yes, to some extent” (scored 50), or “No” (scored 0) Scores averaged across all respondents for the organisation Ability to talk about worries and fears A single question, with wording “Did you find someone on the hospital staff to talk to about your worries and fears?” Responses “Yes, definitely” (scored 100), “Yes, to some extent” (scored 50), or “No” (scored 0) (A fourth response option, “I had no worries or fears”, was ignored for this calculation) Scores averaged across all valid respondents for the organisation Listening carefully A single question, with wording “Did the person or people you saw listen carefully to you?” (N.B. before 2010 this question specifically referenced “your psychiatrist”, rather than “people or person you saw”) Responses “Yes, definitely” (scored 100), “Yes, to some extent” (scored 50), or “No” (scored 0) (A fourth response option, “Don’t know/can’t remember”, was ignored for this calculation) Scores averaged across all valid respondents for the organisation Enough time to discuss needs and treatment A single question, with wording “Were you given enough time to discuss your needs and treatment?” Responses “Yes, definitely” (scored 100), “Yes, to some extent” (scored 50), or “No” (scored 0) (A fourth response option, “Don’t know/can’t remember”, was ignored for this calculation) Scores averaged across all valid respondents for the organisation Formal meetings to review ongoing care A single question, with wording “In the last 12 months have you had a formal meeting with someone from NHS mental health services to discuss how your care is working?” Responses “Yes” (scored 100) or “No” (scored 0) (A third response option, “Don’t know/can’t remember”, was ignored for this calculation) Scores averaged across all respondents for the organisation Treatment with respect and dignity A single question, with wording “Did you feel that you were treated with respect and dignity by NHS mental health services?” Responses “Yes, always” (scored 100), “Yes, sometimes” (scored 50), or “No” (scored 0) Scores averaged across all respondents for the organisation
Longitudinal statistical analysis was conducted in Mplus Version 8. This modelled staff and patient survey outcomes over time to determine any change in responses to questions relating to openness. All analysis was conducted at the trust level, with individual responses aggregated to create the mean, or a percentage score, depending on the type of question. To search for the optimal growth trajectory, piecewise growth curve analysis [
PGCM analysis assumes continuous change following a turning point - however this is not always the case. Change may be temporary before a trajectory returns to its original path, or takes a different direction. Accordingly we tested for the possibility of an interrupted time series using Interrupted Latent Growth Curve Model (ILGM) analysis [
Table Summary statistics for variables in first and final year Survey (Data year) Variable (years measured) First year Final year Mean (SD) Median Range Mean (SD) Median Range NHS Staff Survey Good communication between managers and staff (2008–2017) 26% (7%) 26% (4, 57%) 33% (6%) 34% (14, 48%) Can contribute towards improvements (2008–2017) 63% (8%) 64% (31, 81%) 70% (6%) 70% (40, 79%) Fairness and effectiveness of incident reporting procedures (2007–2017) 3.36 (0.11) 3.36 (2.81, 3.67) 3.73 (0.12) 3.74 (3.17, 4.03) NHS Acute Inpatient Survey Information about condition or treatment (2005–2016) 81% (4%) 80% (73, 93%) 83% (4%) 82% (74, 96%) Involvement in decisions about care and treatment (2004–2016) 71% (5%) 70% (59, 84%) 73% (5%) 72% (63, 89%) Ability to talk about worries and fears (2004–2016) 61% (7%) 61% (43, 81%) 56% (6%) 55% (45, 77%) NHS Community Mental Health Service User Survey Listening carefully (2007–2017) 85% (2%) 85% (80, 90%) 81% (3%) 82% (70, 87%) Enough time to discuss needs and treatment (2007–2017) 80% (3%) 80% (72, 85%) 80% (3%) 75% (59, 82%) Formal meetings to review ongoing care (2007–2017) 55% (10%) 53% (37, 75%) 72% (5%) 71% (59, 83%) Treatment with respect and dignity (2007–2017) 92% (2%) 93% (88, 96%) 83% (4%) 84% (71, 88%) (Full summary statistics for each year can be found in the supplementary material) Annual average scores for NHS Staff Survey questions (percentage scores) Annual average scores for NHS Staff Survey questions (scale score) Annual average scores for NHS Acute Inpatient Survey questions Annual average scores for NHS Community Mental Health Service User Survey questions Piecewise Growth Curve Model (PGCMa) and Interrupted Latent Growth Curve Model (ILGMb) Slope Mean Differences Survey Variable Model Wald Test CFI RMSEA Initial Slope Mean Interrupt Slope Mean Latter Slope Mean Good communication between managers and staff (2008–2017) PGCM 2.94 .965 .063 0.2% 0.7% ILGM 7.70** .969 .061 0.2% −0.1% 0.8% Can contribute towards improvements (2008–2017) PGCM 0.11 .869 .149 1.0% 0.7% ILGM 4.14* .875 .147 1.0% 0.0% 0.7% Fairness and effectiveness of incident reporting procedures (2007–2017) PGCM 13.64*** .831 .161 0.02 0.06 ILGM 8.45** .832 .161 0.02 0.00 0.06 Information about condition or treatment (2005–2016) PGCM 0.05 .865 .087 0.3% 0.6% ILGM 14.37** .885 .080 0.3% −0.1% 0.8% Involvement in decisions about care and treatment (2004–2016) PGCM 9.03** .901 .114 0.4% 0.8% ILGM 0.00 .900 .114 0.4% 0.0% 0.8% Ability to talk about worries and fears (2004–2016) PGCM 4.27* .952 .077 −0.0% 0.2% ILGM 0.08 .952 .078 −0.0% − 0.0% 0.2% Listening carefully (2007–2017) PGCM 11.83*** .207 .175 0.3% −1.9% ILGM 3.03 .226 .174 0.3% 0.5% −1.8% Enough time to discuss needs and treatment (2007–2017) PGCM 8.30** .363 .154 0.3% −1.8% ILGM 0.47 .360 .155 0.3% −0.2% −1.7% Formal meetings to review ongoing care (2007–2017) PGCM 5.16 * .033 .198 1.9% 1.0% ILGM 5.85** .098 .192 1.8% 3.2% 0.5% Treatment with respect and dignity (2007–2017) PGCM 6.04** .000 .243 −0.4% −2.5% ILGM 17.54*** .118 .206 −0.1% −6.6% −0.4% * a PGCM has breakpoint at 2013 b ILGM has step change at 2013–2014 (Fit statistics for competing models can be found in the supplementary material)
Good communication between managers and staff increased from 2008 to 2017 (national averages ranging from 26.0% to a maximum of 33.5%). According to the IGLM (which had better fit), between 2008 and 2013 this increase represented growth of 0.2% per annum (reflecting an average trust-level change of 0.2% in this score each year). There was a slight decrease between 2013 and 2014 (significant at
Opportunities for staff to contribute towards improvements at work increased between 2008 and 2017 (ranging from 61.6 to 70.2%). According to the IGLM (which had slightly better fit), an initial increase of 1.0% per annum between 2008 and 2013 was followed at slower rate between 2013 and 2017 of 0.7% per year. However there was a period of stagnation between 2013 and 2014 (
There was an overall increase in perceptions of the fairness and effectiveness of incident reporting procedures between 2007 and 2017 (ranging from 3.36 to maximum of 3.73 on a 1–5 Likert scale). There was little to choose between the two models: both showed that between 2007 and 2013 this increase averaged 0.02 scale points per year and continued at a faster rate between 2013 and 2017 with an average annual increase of 0.06 scale points. The difference between rate of change pre- and post-2013 was significant (
Between 2005 and 2016 there was an improvement in patients’ views about the amount of information provided by A&E staff (ranging from 80.8 to 83.6%). According to the better-fitting IGLM, between 2005 and 2013 this increase averaged 0.3% per year. Between 2013 and 2014 there was a slight decrease of − 0.1% (
From 2004 to 2016 positive responses about involvement in decisions about your care and treatment ranged from 70.3 to 75.1%. The models fitted equally well, and both indicated that between 2004 and 2013 these increased by an average of 0.4% per year. This continued at a slightly faster rate between 2013 and 2016, at an average of 0.8% per year. The difference in rates of change pre and post 2013 was significant at
Overall between 2004 and 2016 scores for the whether patients had access to someone on the hospital staff whom they could talk to about their worries and fears ranged from 56.6 to 61.5%. According to the slightly better-fitting PGCM, between 2004 and 2013 scores decreased by an average of 0.04% per year; however between 2013 and 2016, this trend changed to one of annual fluctuations in either direction, and on average over this period a slight increase (
For the question, ‘Did the person or people you saw listen carefully to you?’ scores ranged from 81.5 to 88.3%. According to the PGCM (which had slightly better fit), from 2007 to 2013 this increased by an average of 0.3% per year; after this (until 2017) there was a significant decrease (
Scores for the question ‘Were you given enough time to discuss your needs and treatment?’ ranged from 75.5 to 83.1%. According to the PGCM (which had slightly better fit), there was an increase from 2007 to 2013 by an average of 0.3% per year; after this (and up until 2017) there was a significant decrease (
When asked whether they had had a formal meeting with someone in the previous 12 months to discuss how their care is working, responses ranged from 55.1 to 73.9%. Both models fitted poorly, but the ILGM was slightly better. Positive responses to this question increased between 2007 and 2013 by an average of 1.8% per year. There was a significant increase (
Scores for the question, ‘In the last 12 months, did you feel that you were treated with respect and dignity by NHS mental health services?’ ranged from 83.0 to 92.8%. The IGLM was slightly better fitting, and according to this, between 2007 and 2013 this variable decreased by an average of − 0.1% per year; this continued but at a faster rate of − 6.6% (
A discernible change was observed amongst Staff, Inpatient and Mental Health Survey data in the rate and sometimes the direction of change after the publication of the Francis report in 2013.
For Staff Survey variables relating to openness there were some significant improvements after the publication of the Francis report. This included an increased upwards trajectory in the fairness and effectiveness of incident reporting procedures (which was already improving before the Francis report). For communication between managers and staff, and opportunities for staff to contribute towards improvements at work, the increases continued after publication of the Francis report, although not at a higher rate than before.
For Inpatient and Mental Health Survey measures the picture was more mixed. The general trend for the Inpatient Survey was generally positive, with increases at a faster rate during the second period. Specifically, from 2013 satisfaction with the amount of information given to patients in A&E about their condition or treatment increased at a faster rate, and patients’ satisfaction with their involvement in decisions about their care and treatment also increased more sharply.
For the Mental Health Survey the pattern of change was rather different. Patients continued to report better access (as indicated by whether they had attended a meeting to discuss their care in the last year), though at a slower rate after 2014. However, levels of satisfaction indicated in other questions relating to openness deteriorated: patients felt less listened to, believed they were not given enough time to discuss their care, and felt treated with less respect and dignity compared to previous years. Such findings are perhaps noteworthy in view of recent commentary on the disparity between physical and mental health, which includes an imbalance between perceptions, services, resources and funding in favour of physical health [
Mental health has long been considered the poor relation of the NHS [
The paper is not able to explore causal effects between the Francis inquiry and openness because there was no control group. The breakpoint chosen was the year of the publication of the second Francis inquiry, suggesting the inquiry may have had an impact, although of course action in response to the issues at Stafford is likely to have been more diffuse, with organisations making changes in anticipation of the inquiry’s findings, and continuing to act as policies were introduced over the years after the inquiry’s publication. However, we cannot evidence a causal relationship, since other major changes in the NHS were also taking place at the time – most notably the Health and Social Care Act [
Additionally, it may appear that some of the changes found were small in numerical terms. It is difficult to pinpoint exactly what is a clinically or socially relevant change, but it is worth noting that even small changes can produce an important overall population difference when it is multiplied across a service that includes hundreds of organisations, hundreds of thousands of staff, and millions of patients.
Finally, we were unable to take into account different actions that trusts will have acted differently according to their own responses to issues as they occurred, and there is a great deal of variety between types of trust, even within the same broad type (e.g. large teaching hospitals compared with small district general hospitals).
Our findings suggest that from the perspective of staff and to some extent inpatients in acute hospitals, experiences of aspects of care relating to openness have improved through time. While this cannot be attributed directly to the Francis inquiries or to the policy interventions that have followed, our data do suggest that in aggregate, and along with other influences on healthcare provision in England, efforts to improve openness in the sector are having a positive impact. There is evidence that similar initiatives elsewhere in the world, for example efforts to encourage disclosure and reconciliation following serious incidents, have had a positive impact on the views of openness of staff and patients, although ensuring that such policies are implemented in a sensitive and patient-centred way is crucial [
The UK Government has pledged £2.3bn in funding to improve mental health services as part of a ten-year plan focused on prevention and early detection [
This study is part of a wider research mixed-methods project on openness in the English National Health Service: we are grateful to our colleagues in this project, to its funder, and to its professional and PPI advisory groups for their help. GM is supported by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies Institute. The Healthcare Improvement Studies Institute is supported by the Health Foundation – an independent charity committed to bringing about better health and healthcare for people in the United Kingdom. The views expressed in this article are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
JD and GM conceived of the study. The design was developed by JD and IM. IM led data collation and analysis, supported by JD. IM drafted the paper, with critical contributions from JD and GM. All authors approved the final manuscript.
This study was funded by the Department of Health Policy Research Programme (reference PR-R15–0116-23001). The funding body had no involvement the design of the study, in the collection, analysis, and interpretation of data, or in writing the manuscript.
The datasets used in this study are derived from publicly available data from national NHS surveys. The datasets analysed are available from the corresponding author on reasonable request.
Not applicable, as all data used was already in the public domain.
Not applicable.
The authors declare that they have no competing interests.
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