Responding to the Francis Inquiry

Published on Wednesday 6 February 2013, the final report of the Francis Inquiry into failures of care at Mid Staffordshire NHS Foundation Trust has profound implications for the whole of the NHS and for all sectors of pharmacy practice. In the coming months and years all of us will need to respond individually and as organisations to the demand for profound change across healthcare. As your professional body we are making sure that pharmacy plays its part in full in improving healthcare for patients.

On 26 March 2013 the UK Government published its initial response to the Francis Inquiry which stated that “Whilst this poor care was in a hospital, poor care can occur anywhere across the health and social care system. Whether in a care home, at the family doctor, in a community pharmacy, in mental health services, or with personal care in vulnerable people’s homes, we will ensure that the fundamental standards of care that people have a right to expect are met consistently, whatever the settings."

On the 30 April 2013 the Society held an event for the profession to hear first hand from the Francis Inquiry team about the implications for the profession from the inquiry into Mid Staffordshire hospital.

The videos below show Tom Kark QC, and Keith Ridge, Chief Pharmaceutical Officer England, discuss the Francis Inquiry.

Francis videos

What the Society is doing in response to the inquiry

Earlier this year the Royal Pharmaceutical Society held an event to see how the profession should respond to the report by Robert Francis QC, into the tragic events at Mid Staffordshire NHS Trust. The following video highlights the key areas they discussed and what suggestions delegates had as a way to improve in these areas.

Francis Report event presentation

Pharmacists from across the profession spoke to us about what can be done to improve in: safety, information, assurance, transparency, strengthened regulation, culture change, accountability, consistency. 

Francis Inquiry event improvement videos


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How your RPS membership can support you

Leadership and professional support in your day to day practice

The RPS supports its members to be leaders on medicines issues and pharmaceutical care by providing them with updated guidance, the culmination of which is available as an annual publication; Medicines. Ethics and Practice. In addition we have published a leadership competency framework which can help individuals in their development as leaders of teams.

Just culture

Ensuring the environment in which the profession works and delivers care to patients is fundamental to assisting delivery of high quality, safe services by pharmacists and their teams. Professionals need to feel empowered and supported, particularly when they wish to raise concerns. Since January 2011 the RPS have encouraged the development of a just culture within pharmacy. Find more about our work on professional empowerment.

"Blind adherence to targets or finance must never again be allowed to come before the quality of care." (Quote from Patients First and Foremost)

Quality Systems

Over the course of 2013 and beyond, the Royal Pharmaceutical Society will be jointly working with the Pharmacy Forum of Northern Ireland and the Association of Pharmacy Technicians UK (APTUK) to create a resource for pharmacy professionals to maintain and develop the quality of systems of care.Everyone working in healthcare is responsible for the quality of care provided and this resource will be relevant to frontline pharmacy professionals as well as senior leaders within healthcare providers; this is particularly relevant given the unacceptable failings in the quality of care at Mid-Staffordshire Hospital between January 2005 and March 2009.Our objective is to create a user-friendly professional resource that will provide insight and perspective into the “quality levers” within pharmacy and the wider healthcare system. The work will be informed by existing approaches to achieving quality across healthcare and other high-risk industries in the UK and beyond, including hallmarks of quality, and will share these different “quality levers” and methodologies to help pharmacy professionals and leaders to maintain and develop the quality of care provided.The work will contextualise the vital role of professionalism, professional judgment, ethos and values in safeguarding patients, the importance of openness, transparency and candour in the quality system and will run parallel to a programme of government-led activity looking at rebalancing medicines legislation and pharmacy regulation. It aligns with our work to get the culture right, embedding a just, open, safety culture in pharmacy.We are keen on stakeholders helping us to create this professional resource and encourage interested pharmacists to contact our Support Team to register your interest.


The requirement to implement a duty of candour has serious implications for the profession and raises the need to urgently act on decriminalising dispensing errors. Find out more about our work on decriminalisation.

"The NHS Standard Contract for 2013/14 will include a contractual duty of candour on all providers to be open and honest with patients when things go wrong with penalties for breaching the duty. The rationale for a contractual duty is that individual clinical commissioning groups (as opposed to a single national body) are best placed to examine their own local providers and take action where required. A contractual duty placed upon organisations is also the best approach for encouraging staff to be open and report incidents, and thereby promote a positive safety culture. This is because the onus is on the organisation to create a supportive culture in which people can admit mistakes – a challenging, but nonetheless essential task when it involves a needlessly injured patient or relatives who have been bereaved." (Quote from Patients First and Foremost)

We made our view clear on how this would affect the pharmacy profession in our response to the ‘Duty of Candour consultation’.


The UK Chief Pharmaceutical Officers have started a review of the balance between medicines legislation and statutory professional regulation in pharmacy. The review will look at the scope and balance of legislation with a view to ensuring they are “optimally designed” to keep safe those who use pharmacy services, while reducing barriers to the responsible development of practice, innovation and a systematic approach to quality in pharmacy.

The RPS is working closely with the Government, the pharmacy regulator GPhC, and others to ensure the professions voice is heard as this work progresses. Read more about the rebalancing initiative on the Department of Health’s website.

Hospital Standards

The RPS have published standards for hospital pharmacies. These standards underpin the patient experience and the safe effective management of medicines within and across organisations. If applied in practice they will enable hospital pharmacies to demonstrate they are working to a high professional quality and they support implementation of the Francis recommendations. 

Transfer of care principles

The RPS led the development of the principles supporting the transfer of medicines information when patients move between different care providers. Sub optimal care in relation to medicines is responsible for a number of the issues raised in the Francis report.

She was sent home ...and on the first day, we found [she was] unable to administer her own medication [insulin and tablets].Following discharge she had to wait eight hours to collect her medicines

Patient was discharged with no information about her new medication or possible side effects [91 years old and partially blind and deaf]

When she was transferred to a ward there was confusion over her medication

The patient was given new medicines and discharged, yet no one had told her of her diagnosis [epilepsy]

Patient was discharged with tablets..[when] she could only take liquid medication

He was then discharged, without medication, as it was Christmas

The application of our principles will raise the standard of care as patients transfer in and out of hospital, leading to better patient experience and improved patient outcomes. 

Care Homes

Following the CHUMs report the RPS has been working with the National Care forum, the Royal Colleges for medicine and nursing, Care home providers and pharmacy partners to develop tools and resources for Care Homes.. These will be published soon and will provide a wealth of resources to support care workers in care homes as well as identify the ways in which all healthcare professionals can contribute to deliver the best for clients and residents and patients. Within these resources is a Patients Charter which will be invaluable to setting expectations for patients. Residents and their carers for the care they should expect to receive. In addition, the team in Scotland have published ‘Pharmaceutical care in Care Homes’   and are now working towards implementation of the recommendations.

Medicines Optimisation (England)

Pharmacists are the experts in medicines and their use and are leading the medicines optimisation agenda.  Medicines optimisation focuses on getting the best possible patient outcomes from the investment made in their medicines. The RPS has led on the development of ‘Good practice guidance for healthcare professionals’ which incorporates the four principles of medicines optimisation.

RPS Faculty

We are developing a flexible and consistent method of professional recognition of what you do in practice, wherever you work.  For our members delivering services to patients, there is a need to be able to provide evidence of capability (to patients, the public, to commissioners and to employers) as well as evidence of effectiveness.  Additionally changes across healthcare, education, academia and industry mean the entire workforce is much more mobile than previously and as a result, a way of recognising practice and experience will be invaluable.

The launch of the RPS Faculty enables pharmacists to access the first profession-wide pharmacy professional recognition programme and attain post-nominals which will be recognisable to colleagues, healthcare professionals, patients and the public as demonstrating an advanced or specialised level of practice.

NHS Constitution for England

The NHS Constitution is fundamental to provision of care for patients. All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this constitution in their decisions and actions. We will explore how we can support our members to apply the NHS constitution to their everyday practice.

Supporting you to maintain registration

There are also implications for the General Pharmaceutical Council as the regulator for pharmacists and pharmacy technicians.

“The General Medical Council, the Nursing and Midwifery Council and the other professional regulators are hampered by an outdated legislative framework that is too slow and reactive in tackling poor care by individual professionals. As part of the implementation of the Law Commission’s review, we will seek to legislate at the earliest possible opportunity to overhaul radically 150 years of complex legislation into a single Act that will enable faster and more proactive action on individual professional failings." (Quote from Patients First and Foremost)

This talk of 'expert inspectors' might have implications particularly for the care home work;

"As with clinical practice, inspection is both a science and an art, based on knowledge, experience and judgement. To have authority and credibility, inspection must be led by individuals with deep insight and specialist experience in the areas for which they are responsible, with the close involvement of patients, staff and others. The new Care Quality Commission leadership is developing a model of inspection that will secure thorough and insightful inspections which combine first-hand expert experience with data and feedback from patients and staff. The Care Quality Commission will set out their proposals in their new strategy in more detail shortly." (Quote from Patients First and Foremost)