Whose NHS is it anyway? Have your say……

Welcome to the place where you can have your say about “whose NHS is it anyway?” The NHS Alliance – the independent voice bringing together everyone in primary health care – wants to know your answer to this question. All views are welcome. To air your views and to find out further information, please click here.

Notable quote: Making sense of NHS governance

"The ideas, principles and mechanisms constituting governance in the NHS derive from an amalgam drawn from corporate governance, public governance and a variety of other sources. The resulting miscellany presents directors, managers and senior clinicians with a considerable sense-making challenge."

Richard Holti and John Storey – Clinical and non-clinical executive directors’  Sense-making of the new governance arrangements in the NHS. Download here.

House of Commons Health Committee ‘Special Report’ on Patient Safety

The Health Committee has published a ‘special report’ on patient safety relating to the Committee’s patient safety report published in July 2009 (click here).

The Government responded to the patient safety report on 13 October (click here).

This special report sets out the responses to the patient safety report  by the Care Quality Commission and Monitor. It also contains a response by Professor Sir Ian Kennedy (formerly chair of the Healthcare Commission) and a reply to his response from the chairman of the Health Committee.

Of particular interest in the report is Monitor’s responses to various issues around boards highlighted in the original patient safety report.

Download the 27 page ‘special report’ Patient Safety: Care Quality Commission, Monitor, and Professor Sir Ian Kennedy’s Responses to the Committee’s Sixth Report of Session 2008-09 here.

Managing healthcare risk: Out with AS/NZS 4360 – In with ISO 31000

Few people concerned with managing ANY kind of risk in the NHS will not have heard of AS/NZS 4360 – the Australian/New Zealand risk management Standard. The Standard was licensed for the NHS in England in 1999 as part of the Department of Health’s NHS Controls Assurance Project. It introduced to the NHS the concept and practice of risk registers and risk matrices. AS/NZS was subsequently licensed by the rest of the UK NHS and also by the public healthcare system in Ireland.

AS/NZS 4360 is about to be consigned to risk management history. In December 2009 it will be replaced by ISO 31000 – a truly international risk management standard that, essentially, is the next revision of AS/NZS 4360.

Watch a presentation given by Kevin Knight, chair of the ISO working group on the ISO risk management standard, and the driving force behind AS/NZS 4360, on the new Standard and its links with AS/NZS 4360. 

Watch Kevin’s presentation here.

Notable Quote: Sir Stuart Burgess on the board’s conundrum

“How do you equate the total accountability of the board for all that the organisation does with the practical impossibility of knowing everything that is being done in the board’s name?”

Sir Stuart Burgess, quoted in Corporate Governance Countdown

Primary Care Trust fined £10,000 after patient falls 4 metres from a window

North East Essex Primary Care Trust has been fined £10,000 and ordered to pay costs of £4,972 after a vulnerable and partially-sighted patient it was responsible for fell 4.3 metres from a first floor window at Clacton & District Hospital.

The retired 68-year-old suffered a blow to the head and broke his pelvis, shoulder and coccyx in the fall in March last year. The court heard he was known to wander on the ward and had previously suffered four strokes, which had left him mentally and emotionally impaired.

The Health and Safety Executive (HSE) prosecuted the Primary Care Trust (PCT), based at Colchester Primary Care Centre, in Turner Road, Colchester, over the incident. Today representatives of the PCT appeared at Harwich Magistrates’ Court and admitted breaching Section 3(1) of the Health and Safety at Work etc. Act 1974.

The court heard that the patient was staying in the St Osyth Priory Ward at Clacton & District Hospital, in Tower Road, Clacton-on-Sea. At around 10.20pm on Tuesday 4 March 2008, he had wandered into the ward’s first floor day room and fell from an open window to the ground below.

The window was able to open 254mm, but since 1989 NHS standards have required such a window to only open to 100mm by fitting a window restrictor.

Shortly before the incident the PCT was required by the Department of Health to review its window restrictors and identify any that were missing, damaged or defective. This review was not carried out.

HSE Inspector Kim Wicks said:

“North East Essex Primary Care Trust failed in its duty to ensure the health and safety of this retired gentleman, who was left severely injured after his fall, which should never have happened.

“Today’s case should serve as an alarm bell, reminding all Primary Care Trusts how vitally important it is to carry out full risk assessments and act on the findings. The risk of vulnerable patients falling from windows above ground level is well known and there have been a number of similar cases. Equally, the control measures, in this case window restrictors, to prevent this risk are easy to fit and maintain.

“All PCTs must ensure they adhere to recognised NHS safety standards – they are there for a reason. If North East Essex PCT had done so this unfortunate incident could have been avoided.”

“Assessing board effectiveness should be a required component of the annual work programme for all NHS boards”

The Department of Health has published the summary findings of Neil Goodwin’s review of allegations of bullying and harassment of the United Lincolnshire Hospitals NHS trust by the East Midlands Strategic Health Authority (see previous post here).

The review found “no evidence” to support the claims against East Midlands Strategic Health Authority (SHA). However, concerns have been raised about the independence of Neil Goodwin, a former SHA chief executive (click here).

According to Mr Goodwin “Given the increasing pressures on NHS leadership and management that will result from the impact of the economic downturn on public services there is the possibility of firm performance management being interpreted as bullying or harassment.”

Key recommendations made by Mr Goodwin’s relate to improving the performance of board members and boards. In particular, he recommends that “Assessing board effectiveness should be a required component of the annual work programme for all NHS boards and the results included in performance management and regulatory assessments.”

Read the summary findings of Mr Goodwin’s report, along with NHS chief executive David Nicholson’s response here.

Draft regulations for registration system in England breathe new life into clinical governance

The new registration system for health and adult social care in England is described in the post below.

Healthcare Governance Review notes that the draft regulations that will, when finalised and published, set the legal standards framework for registration, require ‘registered persons’ to have “a system of clinical governance and audit.”

According to para. 23(3) of the draft regulations, a “system of clinical governance and audit” means a framework through which the registered person endeavours continuously to -
(a) evaluate and improve the quality of the services provided; and
(b) safeguard high standards of care by creating an environment in which clinical excellence can flourish.

Download the draft regulations here.

Charity Commission disputes Department of Health ruling on NHS charities’ accounts

According to an article in ThirdSector (27 October 2009), The Charity Commission appears to be heading for a showdown with the Department of Health (DH) over accounting procedures for NHS charities in England and Wales.

Senior Department of Health official Janet Perry has told health authorities that any NHS body that is the sole trustee of a charity must move that charity’s assets onto its own balance sheet.

Her position relies on a recently introduced international public accounting standard that says public sector bodies must consolidate the accounts of any organisations they control that have an income above a certain level. The DH estimates this to be about 30 of the 282 NHS charities that have NHS bodies as sole corporate trustees.

But the Commission is planning to write to the health authorities telling them they must not consolidate NHS charities’ accounts. Its official guidance says it is “wholly inappropriate” that charitable funds should ever appear on the balance sheets of public sector organisations, because it gives the impression that charitable assets are controlled by government.

Nick Brooks, head of not-for-profit at accountancy firm Kingston Smith, called the DH position “accounting dogma gone barking mad”. He said: “Consolidation should occur only if there is ownership. If you would not own the funds if the other organisation was wound up, you should not consolidate those funds into your own accounts.”

Jonathan Brinsden, a partner at specialist charity law company Bircham Dyson Bell, said he believed the commission was right to take a stand against the DH, but that corporate trustees would now be left in an invidious position.

“If I was in this situation, it would be impossible to know which authority to listen to,” he said. “Nor do I know how this conflict can be managed.”

A spokeswoman for the Commission said: “We don’t agree with the interpretation in the Department of Health’s letter. We will be following up with the Department of Health on this issue accordingly, and will also be writing to strategic health authority directors of finance to make our position clear.”

Source: ThirdSector – click here.

New registration system for health and adult social care in England from April 2010

From 1 April 2010, the regulation of health and adult social care in England will change. Legislation is bringing in a new system that applies to all regulated health and adult social care services.

All health and adult social care providers, who provide regulated activities, will be required by law to register with the Care Quality Commission. Subject to the new legislation, new registration comes into effect on 1 April 2010 for NHS trusts (including primary care trusts) and 1 October 2010 for adult social care and independent healthcare providers.

By law, the CQC is required to produce guidance about compliance. This makes clear to providers what they need to do to be compliant with the new regulations. The new regulations will replace the existing Standards for Better Health and the National Minimum Standards. There are similar themes from these  in the new guidance about compliance. Some of the evidence that providers used to demonstrate they met the old standards can be used for the new standards.

The CQC stresses, however, that it is important that providers begin to develop new systems which show how they:

• deliver positive outcomes for people who use services;
• capture information about how people experience the services they provide.

Unlike the National Minimum Standards and Standards for Better Health, the guidance about compliance has an enhanced legal status. It can be used as evidence in criminal or civil proceedings and the CQC has stated that it will use it in their enforcement action.

The CQC website is the definitive source of information on the new registration system and will be regularly updated. Find out more, including all about the developing guidance to underpin the new system of registration, here.

Patients at risk from mis-management of medicines

According to a new report by the Care Quality Commission (CQC), patients could be at risk unless the management of medicines between services such as GP practices and hospitals is improved.

The report – Managing patients’ medicines after discharge from hospital – looks at how well patients’ medication is managed after patients leave hospital.

The CQC visited 12 primary care trusts (PCTs), and surveyed 280 of their GP practices and found some evidence of good practice, but also found the following concerns:

• Information shared about patients moving between GPs and hospitals is often patchy, incomplete and not shared quickly enough
• GP patient records are not  always updated by clinical staff
• Too few patients are offered discussions with their GP about managing their medication
• GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

CQC Chief Executive Cynthia Bower says: “There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.”

Download the report Managing patients’ medicines after discharge from hospital here.

NHSLA publishes timeline setting out history of its standards and assessment

A useful timeline has been published by the NHS Litigation Authority as a Powerpoint file.

It sets out the key internal events that have marked the development of the NHSLA risk management standards and assessments, together with the external events that have influenced them from the establishment of the NHSLA in 1995 through to the present day.

Download the timeline here.

NHSLA and NICE joint statement about NICE guidance and risk management

The NHS Litigation Authority (NHSLA) and the National Institute for health and Clinical Excellence (NICE) have issued a joint statement about how compliance with NICE guidance can help trusts manage risk and optimise their resources.

Compliance with NICE guidance is the focus of criterion 5.8 of the NHSLA risk management standards. This requires organisations to have in place approved documentation (Level 1) which describes the process for ensuring that agreed best practice as defined in NICE guidance is taken into account in the context of the clinical services provided by the organisation, that is implemented (Level 2) and monitored and, where monitoring has identified deficiencies, there is evidence that recommendations and action plans have been developed and changes made accordingly (Level 3).

For higher level assessments, every year NICE will provide the NHSLA risk management assessors with a revised list of manual-specific clinical guidelines that will be assessed against during the financial year. Topics will be selected by NICE based on its assessment of those that are current, relevant and could reasonably be expected to have been discussed and implemented within the organisation. The list of clinical guidelines will be included at the back of the specific manuals so that organisations and assessors are aware of the topics selected each year. The assessor will select one clinical guideline from the relevant list to test compliance with the requirements of Criterion 5.8. For interventional procedures the organisation will be asked to indicate the interventional procedures guidance that has been implemented and the assessor will select one from those to test compliance with the requirements of Criterion 5.8.

Download the full joint NHSLA/NICE statement here.

NHS governance related courses from ICSA

The Institute of Chartered Secretaries and Administrators (ICSA) is running three governance related one day courses for NHS participants during November 2009. Detailed are as follows. ICSA says if all three courses are booked you save 20% on total price – a saving of £237.

The NHS Trust Secretary

Price: £395 Date and location: 10 November, London CPD: 6 hours

Click here to view a detailed programme

Understanding Finance in an NHS Trust

Price: £395 Date and location: 17 November, London CPD: 6 hours

Click here to view a detailed programme

Effective Governance in an NHS Trust

Price: £395 Date and location: 24 November, London CPD: 6 hours

Click here to view a detailed programme

Note: This post is provided for information only. Unless specifically indicated to the contrary, Healthcare Governance Review does not endorse advertised training events.

One in 50 episodes of NHS care result from ‘complications’

According to provisional figures released by the NHS Information Centre this month, one in 50 episodes of care commissioned by the NHS, in NHS hospitals or the independent sector, in England resulted from a complication between July 2008 and June 2009.

This equates to 326,000 (two percent) of the 16.3 million episodes during this period, a slight rise compared to the previous 12 month period when 295,000 (1.9 percent; or one in 53) of the 15.6 million episodes resulted from a complication.

A hospital episode relates to a patient’s period of care under one consultant during their hospital stay.

Complications relate to four areas of medical and surgical care in hospital. Between July 2008 and June 2009:

• 95,930 complications (29 per cent of all complications) involved an adverse affect on a patient from drugs used in their treatment.
• 5,050 complications (two per cent of all complications) involved misadventures to the patient during surgical and medical care.
• 3,690 complications (one per cent of all complications) involved an adverse incident relating to medical devices used for diagnosis or therapy.
• 221,150 complications (68 per cent of all complications) involved an abnormal reaction by a patient some time after a surgical or medical procedure, where misadventure was not mentioned at the time of the procedure.

NHS Information Centre chief executive Tim Straughan said: “This is the first time The NHS Information Centre has published a special topic about complications during a patient’s hospital stay. Provisionally it appears one in 50 hospital episodes involve a complication and two thirds of those arise at some point following a surgical or medical procedure.

“It is important to note that complications can occur as a result of patient’s physical reaction to treatment that was not able to be predicted, rather than arising due to any fault of the medical professionals involved. Trends may also include effects of any changes in data recording and clinical coding practices. This information will be useful however to help the NHS examine possible reasons for complications and improve the quality of patient care.”

For further information, click here.

Notable quote: Governance in healthcare

“Governance lives at board level, but its effects should be felt from board to ward.”

Linda Abolins, Lesley Adcock, Juliet Hardcastle, Andrew Jackson, Keith Peskett. Postgraduate programme in healthcare governance, Loughborough University, October 2009.

BMJ research paper adds to evidence of increased patient mortality associated with trainee doctors

A recent Healthcare Governance Review post focused on Dr Foster’s research into the association between increased patient mortality and the August intake of new junior doctors (click here).

The British Medical Journal (BMJ) has published a research paper describing a study that sought to determine whether an increase in the rate of undesirable events occurs after care provided by anaesthetic trainees at the beginning of the academic year.

The ‘retrospective cohort’ study was carried out at the Alfred Hospital, a University affiliated hospital in Melbourne, Australia. The study used administrative and patient record data and the participants involved 19,560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000).

The study found that “The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.”

The study concluded that “Strategies to minimise the rate of undesirable events at the beginning of the academic year should look at improving trainees’ orientation and integration during the first weeks, by developing, for example, mandatory introductory courses, hospital settings’ visits, and interprofessional meetings and, beyond all the rest, by avoiding residents’ involvement in clinical tasks from the first day. The orientation period could also include close one to one supervision, particularly when cross cover work is done in different hospital settings. The systematic use of written documentation of standard working practices should be encouraged to minimise the loss of tacit knowledge associated with staff turnover. Crew resource management programmes such as those developed in aviation and now increasingly introduced in the healthcare environment could be used to improve team coordination and interprofessional collaboration. Finally, early training sessions in simulators could be scheduled to favour rapid improvements in junior trainees’ technical skills.”

The full research paper Rate of undesirable events at beginning of academic year: retrospective cohort study can be freely downloaded here.

Survey of UK surgeons indicates patients are less safe with European Working Time Directive

The Royal College of Surgeons has published the results of its survey into the impact of the introduction of the European Working Time Regulations (EWTR) on surgeons. The results are based on responses by 900 surgeons across the UK and indicate that there is clear evidence that patients are much less safe in the NHS since the August introduction of the 48 hour working limits. The results included the following:

· 64 per cent of all respondents thought quality of care had worsened due to the EWTR.

· More than half of consultants believe compliance with EWTR has been achieved at the expense of patient safety (overall 44 per cent of respondents agreed).

· A third said handover arrangements are inadequate in their hospital and 23 per cent said they cannot stay involved in all stages of individual patients clinical care that require their expertise.

· 62 per cent of surgeons said they were not working a truly compliant 48 hour week with 70 per cent estimating they worked more than 48 hours – with these surgeons estimating they averaged between 55-60 hours a week.

· A quarter of respondents said that other professionals in the healthcare team are acting up to cover tasks previously done by surgeons and 43 per cent said they are covering rota gaps in other areas of their own hospital to keep services running.

Download the summary results here.

NPSA publishes latest organisational incident reports…..but still no learning

The National Patient Safety Agency (NPSA) has published ‘Organisational Patient Safety Incident Reports’ for NHS organisations across England and Wales. The reports summarise incidents reported by staff that have occurred between October 2008 and March 2009, and reported to the NPSA by 30 June 2009.

The figures show that across England, 92.5 per cent of all patient safety incidents result in low or no harm to the patient, 6.2 per cent of incidents are reported as moderate harm to patients, 0.8 per cent as severe harm to patients and 0.4 per cent as contributing to patient death.

The most commonly reported incident type overall is patient accident (32.8 per cent of reports), followed by treatment/procedure (10.1 per cent) and medication (9.4 per cent).

However, as the NPSA continues to fail to collect information on contributory factors and root causes, a principal reason for its establishment back in 2001, the potential for learning from the NPSA reports is limited (see Government response to the Health Select Committee Patient Safety Report here.).

Incident reports by organisation can be downloaded here.

The Government response to the Health Select Committee Report ‘Patient Safety’

The Department of Health has published the Government’s response to the Health Select Committee Report ‘Patient Safety.’

National Reporting and Learning System (NRLS)

The Health Select Committee stated that “After the expenditure of much effort and funding on the National Reporting and Learning System…….we are concerned that the NRLS is nevertheless still limited in its effectiveness.”

Healthcare Governance Review is particularly concerned that despite the ongoing failure of the NPSA to establish a national reporting system in line with Building a Safer NHS for patients, published in 2001, the Department of Health nevertheless contends that “The NRLS is one of the most comprehensive patient safety reporting and learning systems in the world.” We wonder how this statement can be justified given that the Health Committee states that “The [NRLS] currently amasses a good deal of summary data of doubtful usefulness [and] unlike reporting systems in other safety critical industries, and in other healthcare systems, it does not systematically gather in-depth (root-cause analysis) data on serious and sentinel events.”

Managers and Boards

Managers and boards came in for significant criticism from the Health Committee. In particular, the Committee felt that:

1. There was disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust.
2. Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services.
3. Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject.
4. Patient safety is not currently, but must become the top priority of Boards.
5. No Board in the NHS should always be meeting behind closed doors.

The Government appears to have largely accepted the Committee’s finding in relation to management and boards and their responses can be found in the Government’s response document at paras. 49-57, inclusive.

Download the Government response to the Health Committee report on Patient Safety, together with the original patient safety report, here.

Lessons from a review of five London hospital fires and their management

NHS London has published  a review of five significant fires during 2008/09 at NHS sites in London, which required the evacuation of part or whole of the building. Any evacuation of a large commercial building is difficult – coping with a facility as complex as an NHS site, complete with sick and recovering patients, staff and visitors presents further challenges.

The events of 2008/09 proved that with good teamwork, leadership and planning, a safe, successful evacuation of a healthcare facility is achievable. NHS London states that it is imperative that every NHS organisation in London has tried and tested full site evacuation plans.

London’s experiences during 2008/09 demonstrate the critical importance of being prepared for emergencies. The report shares lessons learned from the five significant sires to support colleagues in the wider NHS when developing local plans.

The detailed lessons identified from the five events detailed in the report are clearly laid out in Appendix 2 to provide a checklist for planners and managers across the health service. The report will help to inform the ongoing development of the Department of Health guidance – planning for the evacuation and shelter of people in healthcare settings.

Healthcare Governance Review suggests that NHS boards assure themselves that management in their organisations are well prepared for emergencies and, in particular, have tried and tested full site evacuation plans in place.

Download the report Review of five London hospital fires and their management here.

Credit: Thanks to Peter Aldridge, fire safety manager at Leeds Teaching Hospitals NHS Trust, for bringing this report to our attention.