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.

The framework for Quality Accounts in the NHS in England

The Department of Health has published its official response to the consultation The Framework for Quality Accounts – a consultation on the proposals. It informs the regulation and DH toolkit for 2009–2010 Quality Accounts. The document identifies responses on the:

- Content of quality accounts;
- Publication of Quality Accounts; and
- Which organisations will be required to produce a Quality Account.

According to Professor Sir Bruce Keogh, NHS Medical Director, “the primary purpose of Quality Accounts is to encourage boards to assess quality across the totality of services they offer with an eye to continuous quality improvement. If designed well, the accounts should assure commissioners, patients and the public that trust boards are regularly scrutinising each and every one of their services.”

Following on from the response to the consultation, the document states that “a toolkit will be published alongside the Regulations this Spring that will contain guidance for providers on the production of a Quality Account.”

Read the publication The Framework for Quality Accounts: Response to consultation here.

Foundation trusts, democracy and public ownership – London event, 5 March 2010

The Socialist Health Association is holding an event on Foundation Trusts, Democracy and Public Ownership in London on 5 March 2010. The event may be of interest to some Healthcare Governance Review readers.

The speakers are:

- Patricia Moberly : Is this democracy? Is it public ownership? 
- Malcolm Alexander National Association of Links Members 
- Jessica Asato Director of Progress 
- Hannah Jameson Research Manager Involvement and Participation Association 
- Sharon Carr-Brown Foundation Trust Governors’ Association: Have Governors made a difference? 

The event will be held at Toynbee Hall 28 Commercial Street, London E1 6LS on Friday 5th March 11am – 4pm .

Cost (includes lunch): Statutory and commercial organisations £75, Voluntary organisations £38, Socialist Health Association members £12 (includes members of affiliated organisations such as GMB, Unite and Unison who represent their union or pay their own way).

Unfunded organisations and individuals please contact the Socialist Health Association on 0161 286 1926. 

To book a please, please use the Booking Form at:
http://www.sochealth.co.uk/confs/Booking.htm

Research report on the link between staff and patient experience in the NHS in England

The Department of Health has published a report by Aston University Business School that explores whether the experience of staff working in the NHS links to the patient experience of care.

The evidence underpinning the report is drawn from an analysis of links between the 2007 acute trust inpatient and NHS staff surveys.

The research found a large number of associations between the surveys and puts forward the following key findings:

• The more staff who have had health and safety training, the better the patient perceptions of greater conscientiousness and availability of staff.
• Organisations where staff have clear, planned goals are more likely to have patients who report positive experiences of communication; in particular around patients being involved in decisions on care/treatment, family members being able to speak to doctors, the medical information patients were given, and doctors acknowledging the presence of the patient directly when talking about their case with others.
• When employees are considering leaving their organisation, it is more likely that there are poor levels of communication with patients, particularly around medicine.
• Patient perceptions of staffing levels and the respect and dignity shown towards them are correlated to employee’s feelings of work pressure and staffing levels
• Prevalence of discrimination against staff is related to several areas of patient experience, particularly their perceptions of nursing staff.
• High levels of bullying, harassment and abuse against staff by outsiders relates to many negative patient experiences.
• Staff views on the confidentiality of patient information are mirrored by patient views of the privacy they are given.

The full report Does the experience of staff working in the NHS link to the patient experience of care? An analysis of links between the 2007 acute trust inpatient and NHS staff surveys can be downloaded here.

NHS Wales gets dedicated governance website

The Welsh NHS Confederation has produced a ‘Board Development’ website with the title Getting governance right – a web-based guide to governance in Wales and how to do it well.

According to the Welsh NHS Confederation “With brand new, integrated NHS organisations with large budgets, huge workforces, and far-reaching remits, the principles of good governance are more important than ever before.

“This website brings together a wide selection of advice, practical help and guidance to help board members get to the grips with what is governance, and how to do it well.

“Each section aims to provide practical support in an easily digestible format, helping to arm board members with the knowledge and tools they need to ensure their organisations consistently provide safe, high quality patient care.”

The website “is designed to complement the NHS Wales Governance eManual, developed by the Welsh Assembly Government.”

The Welsh NHS Confederation also runs a Board Development Programme for chairs, chief executives and independent members of Local Health Boards in Wales. The programme is a series of events which provide training, identification of priority policy areas and a background to governance issues.

For further information, click here.

World Bank paper: Governance in health care delivery – raising performance

The World Bank has published a Policy Research Working Paper titled Governance in Health Care Delivery – Raising Performance.

This paper—a product of the Development Economics Department and the Human Development Department—is part
of a larger effort in both departments to understand governance and sector policy.

According to the paper “The impacts of health care investments in developing and transition countries are typically measured by inputs and general health outcomes. Missing from the health agenda are measures of performance that reflect whether health systems are meeting their objectives; public resources are being used appropriately; and the priorities of governments are being implemented.”

The paper suggests that “good governance is central to raising performance in health care delivery. Crucial to high performance are standards, information, incentives and accountability.”

The paper provides “a definition of good governance in health and a framework for thinking about governance.”

Download the paper Governance in Health Care Delivery – Raising Performance here.

Re-imagining corporate governance

In a lecture delivered at Gresham College, London, on 19 January 2010, Professor Kenneth Costa examines the underlying principles of corporate governance and asks “How can governance be designed to minimise abuse without stifling creativity and innovation.”

The lecture is based principally on the well know governance failures in banking, but has some interesting insights that can be applied in other domains, including healthcare.

Read the full transcript of Professor Costa’s lecture, or download an audio file of the lecture, here.

HSJ event 24 March 2010 – Information for Effective Governance

The Health Service Journal (HSJ) is running a one day event in London on 24 March 2010.

Titled Information for Effective Governance, the event will look at ‘effectively identifying, gathering and presenting information to drive forward improvements in governance.’

The event is chaired by Healthcare Governance Review editor Stuart Emslie and includes many distinguished speakers:

Professor Paul Stanton will explore the issue of good information for good governance.

Adrienne Fresko CBE and Sue Rubenstein will outline the new guidance for NHS boards and examine the impact that the guidance will have on NHS organisations.

David Pillsbury will present a case study in establishing effective information systems within NHS organisations and engaging people in their appropriate use.

Andrew Barber will examine the issue of ensuring robust information systems across organisational boundaries.

Caroline Oliver will talk about the Policy Governance approach to developing a holistic Board assurance framework.

Niall O’Gara will examine the specific information governance requirements for PCTs.

John Bruce will talk about overcoming the unique information for governance challenges that Foundation Trust status brings.

In addition to the above, a session is planned to facilitate the development of Board members’ understanding of information.

For further information click here.

Patient Safety First launches ‘Human Factors’ Focus Week

Patient Safety First is urging trusts and healthcare professionals to understand the impact of human factors on healthcare.

As part of its campaign to help trusts eliminate avoidable death and avoidable harm to patients, Patient Safety First is launching, on 1^st February, a ‘Human factors’ focus week. During the week Patient Safety First will be hosting online sessions on different human factors themes and encouraging staff and managers to take one new ‘human factors’ step.

‘Human factors’ issues apply to individuals, teams and organisations; they might be environmental, organisational or job factors, or the individual characteristics that influence behaviour at work. By better understanding the impact of human factors in healthcare, trusts and staff can take one new step in putting patient safety first.

Martin Bromiley, Founder of the Clinical Human Factors Group and core team member of Patient Safety First says: "Clinicians and management alike should never underestimate the impact of human factors in healthcare. To develop a safety culture, trust leaders and managers need to build an organisation-wide knowledge of human factors and how it relates to patient safety, and individuals and teams can use human factors knowledge to make their activities safer. This would go a long way towards creating an environment where staff can feel empowered to challenge observed omissions in care or unsafe practice.”

The ‘Human factors’ focus week launches on Monday 1^st February with an introduction to what human factors is and how it applies to healthcare. Different human factor themes are explored in four further sessions during the week.

To find out more including a ‘How to’ guide on human factors in healthcare and to register for any or all of the online sessions go to www.patientsafetyfirst.nhs.uk.

The sessions include:

· An introduction to human factors, Monday 1^st February (10:30-11:30), hosted by Ken Catchpole (Leverhulme Research Fellow, QRST Unit, University of Oxford) and Melinda Lyons (Human factors lead, National Patient Safety Agency)

· Personal skills associated with human factors – lessons from the aviation industry, Tuesday 2^nd February (08:30-09:30), hosted by Martin Bromiley (Founder, Clinical Human Factors Group)

· Human factors in perioperative care, Wednesday 3^rd February (08:30-09:30), hosted by Jane Reid (Perioperative care intervention lead) and Diane Gilmour (President of the Association for Perioperative Practice)

· Truth and reconciliation following serious harm, Thursday 4^th February (10:30-11:30), hosted by Martin Bromiley, Clare Bowen, Murray Anderson-Wallace and Sarah Garrett

· Human factors – design/ergonomics, Friday 5^th February (09:30-10:30), hosted by Melinda Lyons.

The ‘Human factors’ focus week is one of four dedicated focus weeks that Patient Safety First is holding to help trusts eliminate avoidable death and harm to patients. The other weeks planned are:

· 1st March – Focus on Ventilator care bundles: stories of improvement

· 8th March – Focus on Insulin: ‘Testing a new care bundle for Insulin prescribing’.

For more information please visit www.patientsafetyfirst.nhs.uk

Half of NHS “not capable of saying it is financially viable and well governed” says Bill Moyes

In an interview with The Financial Times, outgoing Executive Chairman of Monitor, regulator of NHS foundation trusts – Dr Bill Moyes – is quoted as saying that “Half the hospital system is still not capable of saying it is financially viable and well governed [the requirements to achieve foundation trust status].”

Read the full article, including a transcript of the interview with Dr Moyes, here.

GovernMENT doesn’t understand governANCE

According to Professor Bob Garrett, author of The Fish Rots from the Head – The Crisis in our Boardrooms, “governMENT doesn’t understand governANCE.”

Professor Garrett was speaking to a cohort of students undertaking the postgraduate programme in healthcare governance at Loughborough University Business School. His comments were made in the context of government’s understanding – including that of government departments and agencies – of the role and function of boards.

Crisis governance

NHS organisations have “an addition to crisis.” So says a recent NHS governance inquiry conducted by the Centre for Innovation in Health Management (CIHM) at Leeds University.

Caroline Oliver, an internationally renowned board governance consultant, believes there is such a thing as ‘crisis governance’ which describes the board’s role in a crisis. This is distinct from crisis management, which describes the role of the executive.

“Board members’ very natural reaction to a crisis is to want to rush in and help” says Caroline. “What this typically means in practice is that board members want to ask lots and lots and lots of questions, about what has gone wrong and why, and then they want to give lots and lots and lots of personal opinions about what should be done about it.   How much does this really help?  I don’t think most boards know, and if they did, my conversations with Chief Executives indicate, they would find that the net effect of such board help has often been to confuse, distract and demoralise rather than improve the situation.” 

Caroline suggests “…….that when crises hit, the real help executives and organisations need from the board is:

a)       A consistent hold on a clearly stated vision for how things should be.
b)       A clear, consistent, and regular demand for accountability from the Chief Executive for the restoration of that vision  as soon as possible.
c)       An incisive understanding of where the organisation is in the meantime.  

Read Caroline’s full article Crisis governance here.

Wishing you a happy and prosperous New Year!

2009 has been a very good year for Healthcare Governance Review.

As we wait for the bells to herald in 2010, the number of hits the blogsite has attracted has just exceeded 36,100 – that means over 26,000 hits in 2009 compared with 10,000 hits during 2008 – the first year of the blogsite’s existence. In other words, we had an average of over 2000 hits per month during 2009 compared with around 800 hits per month during 2008. Thank you for using the site and, if you find it useful, please encourage others to use it.

Wishing you all a happy and prosperous 2010!

The Walker Review of corporate governance in UK banks – implication for NHS boards?

NHS boards might like to review their corporate governance arrangements in the light of the freely downloadable article below, which includes 18 recommendations adapted from the ‘Walker Review.’

Given the experience of critical loss and failure throughout the banking system, Sir David Walker was asked by the Prime Minister to review corporate governance in UK banks. His report – ‘The Walker Review’ – was published at the end of November 2009 and can be downloaded here.

In the Press Release associated with his report Sir David said “The fundamental change needed is to make the boardroom a more challenging environment than it has often been in the past……This requires non-executives able to devote sufficient time to the role in order to assess risk and ask tough questions about strategy………We need to get governance back to centre stage…..…Improved governance can play an important complementary role by instilling greater confidence in the way banks are being run by their boards and overseen by their owners. This should help regulators to strike the right balance.”

The Walker Review makes 39 recommendations covering the following five key areas:

1. Board size, composition and qualification
2. Functioning of the board and evaluation of performance
3. The role of institutional shareholders: communication and engagement
4. Governance of risk
5. Remuneration

The Review proposes that most of the recommendations are enforced through inclusion in the Combined Code on Corporate Governance. This forms the basis of Monitor’s Code of Governance for NHS foundation trusts and, indeed, forms the basis for much of the corporate governance and related guidance issued to the NHS over the past ten years.

Healthcare Governance Review has prepared a short article that looks at key quotations from the review report and suggests what relevant recommendations taken from the report might look like for NHS boards. The recommendations relating to The role of institutional shareholders: communication and engagement and most of the recommendations relating to Remuneration are not relevant to NHS boards and have, therefore, been excluded. Refer to the full Walker Review report for further information on these aspects.

Download the article What the Walker corporate governance recommendations might look like for NHS boards and inspection/regulatory bodies here - Walker Review piece Dec 2009.

Notable quote: regulation, compliance and trust

“…..if you focus so much on regulation, compliance becomes the thing and it erodes trust.”

Gillian Low quoted in an article on Private schools ‘being choked by red tape and tick-box culture’

“Quality [of care] starts at the governance level”

An article in the Otago Daily Times (New Zealand) quotes the Chief Executive of Otago District Health Board, Brian Rousseau, as saying “The Otago District Health Board does not understand the role it will need to take in leading from the top to improve quality of health care if it is to catch up on the rest of the world………I think quality starts at the governance level. The boards need to understand their role in quality and I don’t think they do.”

Mr Rousseau was talking to the Otago Daily Times following a trip to the Institute for Healthcare Improvement’s annual conference in the USA in early December. Following his return from the conference he says “If I take a look at what is happening [in patient safety and quality of care] in the rest of the world, we have slipped behind in New Zealand.”

Mr Rousseau took home a message from the conference that every board member should be asking questions about patient safety, such as "do we really have an open and fair culture?" and "are we always open when things go wrong?" 

While change was needed at board level, Mr Rousseau was also critical of his own performance. As chief executive, it was his role to lead a change of culture in the organisation to a culture focused on quality, he said.

"Probably the biggest problem is lack of time. The reality of a chief executive’s job is there are a lot of other things we deal with. "It is about finding the time to get out of the office and spending time walking around the organisation, talking to people. Finding out more about their roles is a vital step. "I don’t do that enough and it is one of the things I have got to change."

Read the full Otago Daily Times article here.

Patient Safety First to launch ‘focus weeks’ in 2010

Over the first quarter of 2010, Patient Safety First will be running a number of ‘focus weeks’ to promote specific aspects of the campaign to eliminate avoidable death and harm to patients.  

Each week’s activities will be different, but will include practical suggestions about how Trusts can take ‘one new step’ to improving patient safety and suggestions on how to measure impact.  

The activities will be supported by a range of online resources and tools designed to help you make improvements at a local level, and each week will also include opportunities to explore your issues during online discussion sessions with key experts.  There will also be articles, case studies and stories in the professional press and on the Patient Safety First website at www.patientsafetyfirst.nhs.uk 

The ‘focus weeks’ proposed are:

· 18^th January – Focus on Deterioration: ‘Count your calls’

· 1^st February – Focus on Human factors in healthcare

· 1^st March – Focus on Ventilator care bundles: stories of improvement

· 8^th March – Focus on Insulin: ‘Testing a new care bundle for Insulin prescribing’

More details about each of these ‘focus weeks’ will be available nearer the time on www.patientsafetyfirst.nhs.uk

Women in the boardroom and their impact on governance and performance

In October, Healthcare Governance Review reported that Harriet Harman, minister for Women and Equality, has told the Treasury Select Committee that the Britain’s boardrooms must have more women on them (click here).

Speaking on Tuesday 20 October in relation to how boards of City firms could improve Britain’s economic performance through boardroom diversity, she told the Committee “If you want to make sure you don’t have the nightmare of men-only boards, you actually have to change the terms on which men and women participate, you have to change the culture and working practices because the greater good you are aiming for is to make sure you have diverse boards and a proper meritocratic approach.”

Healthcare Governance Review has come across an interesting academic paper Women in the boardroom and their impact on governance and performance by Renee Adams (Australia) and Daniel Ferreria (London).

Adams and Ferreira, in a study of US corporate firms, state that “Many proposals for governance reform explicitly stress the importance of gender diversity in the boardroom. In the UK, the Higgs (2003) report, commissioned by the British Department of Trade and Industry, argues that diversity could enhance board effectiveness and specifically recommends that firms draw more actively from professional groups in which women are better represented. If companies do not voluntarily reserve a minimum of 25% of their board seats for female directors, Sweden has threatened to make gender diversity a legal requirement ………The most extreme promotion of gender diversity occurs in Norway, where since January 2008 all listed companies must abide by a 40% gender quota for female directors or face dissolution.”

In their paper, Adams and Ferreira say they provide new evidence that is relevant to the ‘women on boards’ debate by investigating the hypothesis that gender diversity in the boardroom affects governance in meaningful ways. In particular, they ask the following questions. First, do measures of board inputs (director attendance and committee assignments) vary with gender diversity? Second, does the gender composition of the board affect measures of governance, such as chief executive officer (CEO) turnover and compensation? Finally, does the effect of gender diversity on governance matter sufficiently to affect corporate performance?

The researchers found that gender diversity in boards has significant effects on board inputs. Women are less likely to have attendance problems than men. Furthermore, the greater the fraction of women on the board is, the better is the attendance behaviour of male directors. Holding other director characteristics constant, female directors are also more likely to sit on monitoring-related committees than male directors. In particular, women are more likely to be assigned to audit, nominating, and corporate governance committees, although they are less likely to sit on compensation committees than men are.

Women also appear to have a significant impact on board governance. The researchers found direct evidence that more diverse boards are more likely to hold CEOs accountable for poor performance.

The evidence on the relation between gender diversity on boards and firm performance was more difficult to interpret. The researchers found that firms perform worse the greater is the gender diversity of the board. This result is consistent, they say, with the argument that too much board monitoring can decrease shareholder value. Thus, they conclude, it is possible that gender diversity only increases value when additional board monitoring would enhance firm value.

If the key findings of Adam’s and Ferreira’s research can be extrapolated to the case of NHS boards, who tend to ‘fail’ because of a lack of sound monitoring of management, we might reasonably conclude that more diverse boards would be more likely to hold the CEO accountable for poor performance and, in general, would enhance board monitoring of management.

The full academic paper Women in the boardroom and their impact on governance and performance by Renee Adams and Daniel Ferreira can be downloaded here.

Legal action warning issued to NHS bodies not complying with the Race Relations Act

The Equality and Human Rights Commission has issued compliance notices to three NHS organisations warning that they need to take steps immediately to address race equality or face legal action for failing to comply with the Race Relations Act.

The Commission believes Frimley Park Hospital NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust, and NHS Surrey are in breach of the Act’s Race Equality Duty. This Duty requires certain public authorities to eliminate racial discrimination, and promote equal opportunities and good race relations.

The Trusts have failed to put in place compliant Race Equality Schemes that set out how they will meet the Duty including:

• an assessment of functions and policies relevant to race equality
• the arrangements for monitoring policies for any adverse impact on the promotion of race equality
• assessing and consulting on the likely impact of proposed policies on the promotion of race equality
• training staff on how to adhere to the Duty

In addition, NHS Surrey and Kent and Medway NHS must take particular steps to improve their employment monitoring in accordance with their obligations under the Race Relations Act. Obligations required of listed public authorities include putting in place arrangements to monitor the ethnic background of staff and applicants for jobs, promotions and training, as well as monitoring the number of staff from each racial group who are involved in grievance procedures, subject to disciplinary procedures or cease employment with them.

Each Trust has also failed to carry out equality impact assessments on policies. The Commission has asked the Trusts to address these deficiencies.

The three NHS Trusts have received a compliance notice which is the first step in formal legal action. They have three months to put the scheme and monitoring plans in place. Failure to deliver may result in an application to the County Court.

The Commission is writing to a number of other Trusts about concerns it has with their failure to comply with race laws. The Commission is also in discussion with the Strategic Health Authority about how they can play a leading role in improving the standards of compliance by Trusts within their area.

For further information on this post, click here.

GMC calls for national prescription chart to reduce prescription errors

Prescribing errors in hospitals could be reduced if a standardised prescription chart was introduced in all UK hospitals, according to research commissioned by the General Medical Council (GMC).

An in-depth study into the causes and prevalence of prescribing errors made by Foundation Year 1 doctors (first year foundation trainees) has found that prescription errors are not solely, or even primarily, a problem of the most junior trainees and that doctors at all levels, including consultants, make mistakes.

The study showed that the causes of the errors, such as miscalculating the dose, were complex and included straightforward human or communication errors that happen in busy and stressful working environments. Some of the errors were as a result of the system the doctor was working in, including complex or unfamiliar prescribing charts. The research team, led by Professor Tim Dornan, checked 124,260 medication orders across 19 hospitals. Of these 11,077 contained errors, an error rate of 8.9%. Of the total orders checked, 50,016 were written by Foundation Year 1 doctors, an error rate of 8.4%.

The report stresses that very few prescribing errors caused harm to patients because almost all were intercepted and corrected before reaching them. The intervention of nurses, senior doctors and, in particular, pharmacists was vital in picking up errors before impacting upon on patients.

The report contains many recommendations regarding training of doctors. The recommendations and findings will also be of interest to managers within the NHS and other healthcare providers.

Read the full GMC press release here.

Read the full report here.

UPDATE: 14 December 2009. The Lancet publishes a free article on How to reduce prescribing errors (Free registration required). Click here.

Notable quote – board accountability

Most readers will be well aware of the recent furore regarding mortality rates and NHS regulation. According to an article in the Health Service Journal (HSJ – 3 December 2009) NHS Confederation policy director Nigel Edwards said “Inspection is hugely burdensome. Regulation should be a backstop – the foundation stone is board and professional accountability.”

Read the HSJ article here (registration may be required).