Membership Governance in NHS Foundation Trusts – A Review for the Department of Health

In June 2007, the Department of Health commissioned two external organisations – Mutuo and the University of Birmingham, to lead on an independent review on behalf of Ministers into membership governance in NHS foundations trusts (NHS FTs). The main focus of the review centres around the experience of creating a membership, establishing a board of governors and deciding how best to use members and governors. Supporting material was obtained from Monitor, the Foundation Trust Network and the Department of Health, however, Mutuo and the University of Birmingham are alone responsible for the draft.The review is intended to be an easy to read study into membership governance, setting out the origins of NHS FTs, the review’s findings and a number of conclusions.

Ministers have welcomed the review as a constructive contribution to discussion of governance arrangements in NHS foundation trusts.

Download the review report here.

Primary Care Trust boards urged to appoint sexual health representative

In the latest ‘madness’ around populating NHS boards with representatives for everything, the Department of Health’s Independent Advisory Group on Sexual Health and HIV is urging Primary Care Trusts (PCTs) to “Designate a board-level lead for sexual health who is accountable to PCT and LA chief executives and takes the lead on driving forward local strategy.” This recommendation is set out in the Group’s review of the national strategy for sexual health and HIV published on 25 July 2008.

 

To access the Group’s National Strategy for Sexual Health and HIV, click here.

NHS risk management conference

The Health Service Journal is running a one day risk management conference on 15 October 2008 in Birmingham.

Chaired by Patrick Keady, Chair of the IOSH Healthcare Group, the conference theme is ‘Identifying and mitigating healthcare risk.’

Planned conference presentations include:

- Embedding a holistic approach to risk management
- Raising the profile of risk at all organisational levels and improving risk management practice
- Overview of legal compliance and regulation
- Effective risk management across partnerships
- Managing organisational risk as a Foundation Trust

For further information, and to register for the conference click here.

Network governance – useful resources

An enquiry was received by Healthcare Governance Review regarding governance of network services in the NHS.

NHS Networks provides a wide range of very helpful resources on all aspects of running networks, including information on governance and related issues. These resources can be accessed here.

Ireland reports on its national patient safety incident reporting system

The Health Information and Quality Authority (HIQA) in Ireland has published the results of the evaluation of STARSweb, the Internet hosted incident reporting and claims administration system used in public acute hospitals to report errors, near misses and clinical incidents. The system is aimed at supporting patient safety systems and is similar in concept to the National Reporting and Learning System (NRLS) developed by the National Patient Safety Agency.The evaluation included a literature review, a data quality audit of the STARSweb system, a survey of staff using the system, and interviews with healthcare enterprises.

It was determined that the information submitted via the STARSweb system was found in general to be appropriate, but that data submitted was not as comprehensive as it ought to be.”

The evaluation identified that the majority of the incidents logged are minor in nature and are reported primarily by nursing staff. It is recognised that reporting from the system at national level is underdeveloped and therefore major learning opportunities are lost. However, it is acknowledged that there is significant potential for addressing this issue and the recommendations contained within the report address this.

Although future development of the system is required, the evaluation found that the STARSweb system is appropriate for the collection of data relating to clinical incidents.

It also recommends that reporting issues in healthcare institutions be addressed. The report identifies 15 specific recommendations relating to the Clinical Indemnity Scheme, the Health Service Executive, and the Health Information and Quality Authority.

For further information, including the final report, click here.

Irish Investigation Report into the Pathology Service and the Symptomatic Breast Disease Service at University Hospital Galway

The Health Information and Quality Authority has published the report of its investigation into the provision of services to Ms A by the Health Service Executive (HSE) at University Hospital Galway (UHG) in relation to her symptomatic breast disease, and the provision of Pathology and Symptomatic Breast Disease Services by the Executive at the Hospital.

Ms A was a patient at Barrington’s Hospital, a private hospital in Limerick, but, as was the practice at the time, her pathology samples were sent to the pathology department in UHG for analysis. The Authority’s investigation focused on the services provided to Ms A by UHG, given that it is authorised to conduct investigations into HSE funded hospitals only. A separate investigation was conducted by the Department of Health and Children and Barrington’s Hospital into Ms A’s care in that hospital (published April 2008).

In relation to Ms A’s care, the main findings of the Report are as follows:

- Two different pathologists working in UHG misdiagnosed Ms A’s breast cancer – Dr B in September 2005 and Dr C, a locum pathologist, in March 2007;
- As a result of the misdiagnosis which occurred, Ms A’s treatment for breast cancer was delayed;
- There was no arrangement in place for pathologists from UHG to participate in multidisciplinary review of cases at Barrington’s Hospital and as a result, an important opportunity to correct for these interpretative errors was lost;
- Although UHG was paid for the service, the agreement between the two hospitals was based on an informal arrangement between clinicians, and no formal governance arrangements were in place to oversee the service.

To ascertain whether there was a need for wider concern about the work of Dr B and Dr C, and to ensure as far as possible that no other patient had received a misdiagnosis, the Investigation Team reviewed the caseload of the two pathologists. This entailed reviewing 200 breast histology patient cases reported on by Dr B and 747 breast and non-breast cytology patient cases and 123 gynaecological cytology cases reported on by Dr C. This review found that in the case of Dr B, a single interpretive error, the misdiagnosis of Patient A, occurred and there was no cause for wider concern about their work. The review of Dr C’s work identified 49 patients where the reviewers differed from Dr C in their findings. The discrepancies found in these 49 patients had the potential to affect the clinical management and care for those patients and therefore all patients were followed up by UHG and, where necessary recalled for consultation, further investigation or treatment. Of the 123 gynaecological cytology cases reviewed by the Investigation Team, 35 women whose specimens were reported on by Dr C were contacted for precautionary follow-up as a result of a difference of opinion between the review and Dr C’s reporting.

Although carried out according to guidance in place at the time, some aspects of Dr C’s appointment also raise questions for UHG and the wider HSE. A number of specific recommendations in the Report deal with this issue.

As in many countries, the current recruitment process for permanent, temporary or locum consultants does not include objective assessment of technical ability but relies on the subjective opinion of referees. Clear procedures for the recruitment of temporary or locum staff, including comprehensible guidance on the use of recruitment agencies and guidance on references should be developed and applied across the broader HSE. Such procedures are particularly important given the reliance on locum staff within the health services. The Minister of Health, Mary Harney, said: “The system’s over-reliance on locums, and the procedures used in recruiting them, is now being addressed by the HSE. The HSE is implementing a series of measures to strengthen its procedures for recruitment in this regard.”

Commenting on the Report, Jon Billings, Director of Healthcare Quality, in the Health Information and Quality Authority, said: “The fact that Ms A experienced two interpretive errors, separated by 18 months, by two different consultant pathologists serves to emphasise the importance of having fully functioning triple assessment and Multidisciplinary Team Meetings (MDTs) in place, irrespective of where the patient is cared for. Failure by the clinicians and institutions concerned to have such arrangements in place was a significant factor in her delayed diagnosis.”

“Overall, the Investigation Team found that the Symptomatic Breast Disease Services at UHG were well run – although it makes recommendations for improvements in the Pathology Department’s quality assurance systems. The Hospital was responsive once the interpretive errors came to light. Lessons learned by UHG in responding to this incident should be examined by corporate HSE to inform the approach adopted nationally,” said Jon Billings.

The Report makes 12 recommendations which it believes must be implemented by the HSE in order to safeguard the delivery of a quality service to patients. The Report states that the corporate HSE executive management team should nominate a specific Director accountable for ensuring the development of an implementation plan for these recommendations. This, it recommends, should include a clear timeframe with milestones. Progress against the plan should be made public and reported to the Board of the HSE.

 For further information, including access to the report, click here.

Oxford NHS trust fined for patient safety incident

The Health and Safety Executive (HSE) is advising hospitals and other establishments, such as care homes where there are vulnerable persons, to ensure all baths and showers are fitted with Thermostatic Mixing Valves (TMVs) following the prosecution of the Oxford Radcliffe Hospitals NHS Trust on Monday 21 July 2008. The Trust, which runs the John Radcliffe Hospital in Headley Way, Oxford, was fined £8,000 and ordered to pay costs of £2,286.15, and £500 in compensation, as well as a £15 victim surcharge, at Oxford Magistrates’ Court following an injury to a patient in their care.

The Trust pleaded guilty to charges under section 3(1) of the Health and Safety at Work etc Act 1974 for failing to ensure the safety of one of its patients.

On 10 October 2007 an elderly patient was scalded when taking a bath. The temperature of the water from the hot tap was approximately 55 degrees Celsius and she suffered burns to her body. The patient was discharged six weeks after the incident, though she had been due to leave on the day the incident occurred. The bath involved was one of four in the hospital, not fitted with TMVs.

Prior to the incident there was no formal protocol for assessing individual patients’ capabilities for bathing and no formal safety inspections of water temperatures.

Matthew Lee, HSE Inspector, said:

“The Trust took immediate action following the incident to ensure that all baths in the hospital were fitted with TMVs and have implemented a comprehensive range of improvements to ensure that there can be no repetition of this type of incident.

“I would advise those who care for vulnerable people to ensure they have adequate controls in place to prevent a similar accident occurring.”

The HSE notice regarding this prosecution can be downloaded here.

Insight into ‘board to board’ (B2B) meetings with Monitor

An interesting article in the Health Service Journal (HSJ) sees David Lee, director of strategic development at Camden and Islington Mental Health and Social Care foundation trust, provide enlightenment on ‘board to board’, or ’B2B’ meetings with Monitor, regulator of NHS foundation trusts.

The full HSJ article can be viewed here.

Updated publication explores principles behind developing NICE guidance

The National Institute for Health and Clinical Excellence (NICE) has published the second edition of Social Value Judgements: Principles for the Development of NICE Guidance. The guidance describes the principles that NICE should follow in designing the processes it uses to develop its guidance and in developing individual pieces of guidance. It is mainly about the judgements that NICE and its advisory bodies should apply when making decisions about the effectiveness and cost effectiveness of interventions, especially where such decisions affect the allocation of NHS resources.

The updated NICE guidance can be downloaded here.

Audit Commission study on how NHS boards get their assurance

The Audit Commision is undertaking a new study looking at the rigour of NHS board assurance frameworks, specifically how boards assure themselves about the strength and completeness of their internal controls to support the accounting officer’s statement on internal control (SIC) and therefore the reliability and accuracy of their self assessment and self certifications for regulatory purposes. 

The Audit Commission will be working with Monitor on the study and therefore will focus on NHS trusts and foundation trusts. The study will focus on the evidence provided to boards to enable them to make their core standards declarations and for the accounting officer to sign the SIC. The study will therefore review how key risks are identified and managed and whether key systems and processes support the measurement and mitigation of those risks.

The Audit Commission will be looking at internal audit plans and whether they include appropriate resources and the necessary skills to focus on the key risks identified. They also plan to review the information reported to the board, the audit committee and the accounting officer and how they respond to the information provided, including whether there is appropriate challenge to the information they receive.

At this stage the Audit Commission expects their recommendations to cover:

- an overview of the main areas boards should consider with regard to the assurance they require;
- the improvements which boards should themselves make;
- of internal audit and other external advice to provide assurance;
- what, if any, changes should be made to the regulatory system in order to encourage improved assurance;
- what, if any, changes are needed to the Department’s NHS Internal Audit Standards and the guidance provided to audit committees; and
- what changes should be made to provide better assurance on data quality, including changes to be implemented in 2008/09.

The research will be taking place over the summer and the report will be published in autumn 2008. For further information about the study, contact Emma Knowles on 0844 798 2747 or e-knowles@audit-commission.gov.uk

UK Parliament to investigate patient safety

The UK Parliamentary Health Select Committee is to start an investigation into patient safety later this year. Among the issues it will examine are the role of human error and poor clinical judgement, the impact of public perceptions of risk on NHS policy, and the effectiveness of boards in establishing a safety culture.

The full terms of reference for the investigation can be downloaded here.

Written evidence should be sent to healthcommem@parliament.uk by 22 September 2008.

Hospital board dynamics – Five key questions from the USA

Research carried out by Harvard School of Public Health in Boston has identified the following five questions as important for board members to ask themselves to assess the health of their board’s dynamics.

- The roles played by management and the board
- The inclusiveness of all board members, not just a small subset, in the decision-making processes
- The usefulness and transparency of educational guidance and information
- The level of respectful disagreement among trustees
- The board chair’s role and his or her dedication to performing it.

The aim of the reseach study was to explore governance differences between high and low-performing non-profit hospitals as a way to identify best practices in hospital governance and, conversely, to identify specific governance problems of poorly performing hospitals. To do this, the researchers focused on the behavioral dynamics of boards. Study findings are based on 73 trustee interviews conducted in nine hospitals, adapted from questions developed by the Center for Healthcare Governance of the American Hospital Association.

Further details on the study can be accessed here.

Health Care Risk Report Vol 14 Issue 8 July/August 2008

This issue of Health Care Risk Report (HCRR) focuses on the 60th anniversary of the NHS and has a distinctly ‘patient safety’ theme.

The tone is set in the Forword by Ann Keen MP, parliamentary under-secretary for the NHS, which is titled ‘Patient safety is our priority.’

Pat Anderson, editor of HCRR, reports from May’s Patient Safety Congress that patient safety is now a priority for MPs, managers and clinicians. As Pat says, David Nicholson, Chief Executive of the NHS, has “now made clear to NHS Chief Executives that quality and safety [is] central to their role….” He also said that the English patient safety campaign would not be part of performance management as this would “be the best way of killing it.” Pat completes finished her article on the English national patient safety outlining the national director, Stephen Ramsden’s, view that the campaign would be “led by the service for the service” and that its cause would be “to make the safety of patients  highest priority”, and its aim would be “no avoidable death, no avoidable harm.”

Martin Fletcher, CEO of the National Patient Safety Agency outlines three key patient safety challenges for the next 60 years – building stronger partnerships with patients; the opportunity – and risk – of new technology; and the opportunity for better design for safety.

Brian Capstick provides a short article on learning from incident reports. He concludes that the way forward is to have better quality data on incidents being recorded, and this date should include an account of how much incidents are costing the NHS.

Jackie Cresswell provides a useful summary and timeline around patient safety in the NHS, starting with the establishment of Action for Victims of Medical Accidents (now Action against Medical Accidents, or AvMA) in 1982, and ending up with the patient safety campaign launches in Wales and April in 2008.

Other articles include:

- 60 years of health and safety in the NHS;
- The NPSA’s ‘Foresight Training’ for nurses, which aims to enlighted nurses on factors that can predispose to errors; and
- Patient safety heros: a tale of ‘comic strip’ posters at Barts and the London NHS that include ‘good’ characters such as ‘Reporting Man’ and ‘Detective Investigation with his Root Cause Analysis Droid’, and ‘evil’ characters such as ‘The Punisher’ and ‘Blame Monster’. Intriguing, no?

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

NHS foundation trust board performance research features in first issue of new ‘Clinical Leader’ journal

The British Association of Medical Managers (BAMM) has launched its new peer reviewed journal Clinical Leader.

The first issue of Clinical Leader contains an academic paper by Healthcare Governance Review editor, Stuart Emslie, describing his recent research into the relationship between board and organisational performance in NHS foundation trusts (see earlier HGR post on the subject here).

With the kind permission of BAMM, a copy of Stuart’s paper can be downloaded here.

For further information on BAMM’s new Clinical Leader journal, contact Robin Scott, Editorial Assistant, BAMM Publications on robin.scott@bamm.co.uk

Providers treating NHS patients to be made to publish ‘quality accounts’ alongside financial reports

According to the Health Service Journal (HSJ), from April 2010 all providers treating NHS patient will have to publish “quality accounts” alongside their financial reports. These are intended to provide patients with easy to read information on health outcomes. The shift from monitoring targets and process indicators of performance to health outcomes is a key feature of the Darzi review of the NHS in England.

By 2010-11 up to 3% of annual hospital trust income will be contingent on meeting service quality requirements, which will include trust performance in relation to patient reported outcomes of care.

As part of the new quality drive, and to ensure effective implementation of Lord Darzi’s recommendations, the Department of Health (DH) is setting up the National Quality Board. It will report to the health secretary and be chaired by the NHS chief executive, David Nicholson. As reported in the HSJ, however, Nuffield Trust director Jennifer Dixon has said the board introduced a further “blurring” and confusion over the remit of regulators – specifically Monitor and the Care Quality Commission – and performance management.

Local accountability of health services – Discussion paper

The Democratic Health Network (DHN), part of the Local Government Information Unit (LGiU), provides policy analysis, training and support to its members on the involvement of communities in shaping local health care. It has recently published a discussion paper relating to new mechanisms it feels are needed to hold the NHS to account locally. According to an independent survey conducted on behalf of the LGiU, 65% of surveyed elected members said new mechanisms are needed to hold the NHS to account locally.

The paper, Out of Our Control? The Case for Better Health Accountability sets out practical measures to give the community and their elected representatives greater influence over the planning, delivery and review of health services. The publication aims to influence government plans for a constitution for the NHS to assure national and local accountability.

To read the paper click here.