Paul Stanton on the need for wisdom in NHS boardrooms

Writing in the Health Service Journal (26 November 2008), Paul Stanton, former head of board development with the National Clinical Governance Support Team, believes that “Rules-based systems throttle governance – which,” he says, ”by its nature, is the application of wisdom to uncertainty.” He goes on to say that he ”can foresee no early end to uncertainty. Let us all, non-executives and executives alike, do all we can to ensure that wisdom prevails in the boardrooms of the NHS.”

Paul’s comments are made in the context of the global credit crunch and its impact on public sector and, particularly, NHS organisations. According to Paul, “A prudent and well-governed NHS organisation will already be planning for reduced resources and increased demand. Never has authoritative and effective governance been more important. Arguably, on a global scale, it has never been more scarce.”

He contends that “The current global crisis and the demands it will impose on local NHS organisations – alongside re-regulation (that is revised regulation – as opposed to de-regulation) under the auspices of the Care Quality Commission – should provide a powerful stimulus to align the approaches to system regulation and to organisational governance to ensure both go beyond the prescriptive rules-based “ticknology” that has so singularly failed in the private sector and increasingly blighted the NHS.”

In other words, says Paul, ”regulation and governance should be principle and value based – with regulatory rules kept to the minimum that is consistent with clarity, transparency and effective enforcement in the interests of the protection of the vulnerable.”

Given Paul’s recent comments on the “confusion and muddle” in the Department of Health and NHS around the nature of governance (click here), Healthcare Governance Review wonders whether sufficient wisdom currently exists within the system to get NHS governance right.

Read Paul’s full HSJ article here.

Trust boards need to learn different approach to performance management required to engage staff in improving quality

Responding in the Health Service Journal (20 November 2008) to the Department of Health’s recently published framework for improving the quality of NHS care, Royal Salford NHS foundation trust chief executive, David Dalton, says that ”many trust boards would need to learn the different approach to performance management required to engage staff in improving quality.”

“Without it,” he says ”there will be no real ownership and there will be dis-satisfaction when existing approaches to performance management are not seen to bring results.”

For further information, click here.

WARNING! Poor leadership may damage employees’ hearts

A study published in the Journal of Occupational and Environmental Medicine addresses the impact of leadership on the heart disease among employees.

A Swedish team found a strong link between poor leadership and the risk of serious heart disease and heart attacks among more than 3,000 employed men. And the effect may be cumulative – the risk went up the longer an employee worked for the same company.

Researchers from the Karolinska Institute and Stockholm University tracked the heart health of the male employees, aged between 19 and 70 and working in the Stockholm area, over a period of nearly a decade. During this time 74 cases of fatal and non-fatal heart attack or acute angina, or death from ischaemic heart disease, occurred.

All the participants were asked to rate the leadership style of their senior managers on competencies such as how clearly they set out goals for their staff and how good they were at communicating and giving feedback. The staff who deemed their senior managers to be the least competent had a 25% higher risk of a serious heart problem. And those working for what was classed as a long time – four years or more – had a 64% higher risk.

The findings held true, regardless of educational attainment, social class, income, workload, lifestyle factors, such as smoking and exercise, and other risk factors for heart disease, such as high blood pressure and diabetes.

The researchers, which included experts from University College London in the UK and the Finnish Institute of Occupational Health, said that if a direct cause and effect was confirmed, then managers’ behaviour should be targeted in a bid to stave off serious heart disease among less senior employees.

They said managers should give employees clear work objectives and sufficient power in relation to their responsibilities.

Source: BBC – click here.

For further information, click here.

“For PCTs to move from good to great, boards must be a force for continuous improvement and public accountability”

So says Sefton PCT chief executive, Leigh Griffin, in an article on PCT boards in the Health Service Journal (1 November 2008).

In the article he explains: “Board development is critical for boards to demonstrate strategic leadership, ambition, focus, challenge and understanding. The raised expectations on PCTs must, first and foremost, be understood and driven at board level”.

Also in the article, Gary Belfield, director of commissioning at the Department of Health, observes that international evidence suggests the two main features of any organisation making a real difference and starting to succeed are “having great top leadership and a strong, cohesive board”.

Read the HSJ article here.

Notable quote: On the accountability of doctors…

“It is difficult to make doctors accountable for their actions as they are used to a great deal of autonomy, public esteem and respect. They are used to being in control.”

John Tingle, Health Care Risk Report, November, 2008

Health Care Risk Report Vol 15 Issue 1 November 2008

A mixed-bag of goodies awaits the reader in this issue of Health Care Risk Report (HCRR).

In the second of two ‘peer reviewed’ linked articles, Professor Louise Wallace describes two examples of successful use of patient safety newsletters, and recommends how such newsletters could be improved.

Sir Jonathan Michael, chair of the Independent Inquiry into Access to Healthcare for People with Learning Disabilitiesand Anne Richardson, head of offender mental health at the Department of Health, lay out the recommendations of the inquiry into healthcare for people with learning disabilities, and what these mean for the NHS.

John Tingle, a regular contributor to HCRR, looks at reports issues by the Royal College of GPs and the Medical Defence Union that provide important perspectives on proper medical practice and good risk management. He says that “It is difficult to make doctors accountable for their actions as they are used to a great deal of autonomy, public esteem and respect. They are used to being in control. The independent contractor status of most GPs compounds this. One of the reasons why the implementation of clinical governance in primary care has been very patchy is because it is difficult to tell self-employed professionals what do do.” Consequently, says John Tingle, “It is…..necessary for the protection of society to impose external accountability mechanisms to police the profession and to ensure proper standards.”

Dr Jiju Antony, professor of quality management at Strathclyde University, in the second of two articles looking at Lean and Six Sigma in healthcare, describes a pilot study of the effect of Lean and Six Sigma on service quality and safety in NHS trusts. He concludes that NHS Scotland “has quite a long way to go before Lean Six Sigma, or even any type of Six Sigma effort, becomes a normal part of the organisation.”

In a short article on the subject, Charles Hancock, director of healthcare programmes at Loughborough University Business School argues that nurses need better fire training. And an article by Stuart Emslie, Editor of Healthcare Governance Review, describes the Irish report on patient safety, which sets out a world-class healthcare governance framework.

Finally, and again in the second of two articles, this time looking at the Mental Capacity Act deprivation of liberty standards, solicitor Andrew Alonzi looks in more details at the code of practice.

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.

DH publishes framework for improving the quality of NHS care

The Department of Health (DH) has sent details to all NHS organisations on how they should approach the commitments made in Lord Darzi’s next stage review, which makes improving quality the centrepiece of the next decade of the NHS.

Each tier of the NHS – from local clinical teams to boards, strategic health authorities and the National Quality Board – is being asked to select the indicators it wants to use to measure, compare and improve the quality of services.

The full suite of quality framework documentation can be accessed on the DH website here.

The Health Service Journal (HSJ – 20 November 2008) has produced an excellent article summarising the DH requirements and reporting on an interview with Lord Darzi. There is also a video on the quality framework.

For further information, and to watch the quality framework video, access the HSJ article here.

Intelligent Information for Effective Governance – HSJ conference, London, 22 January 2009

Readers are reminded that the Health Service Journal (HSJ) is running a conference on Intelligent Information for Effective Governance – Developing smart systems to empower strategic decision-making at board level, on 22 January 2009 in London.

According to the HSJ, good governance is underpinned by intelligent information. There is a tendency across the country however, to overload the Trust Boards with too much information, hindering their ability to function effectively. This is a key challenge for many Boards – especially with the implementation of the new NHS performance framework, and the emerging threat of the NHS failure regime.

This conference has been specifically designed to provide delegates with the tools and guidance they need to streamline and strengthen information flows to Trust Board, and ensure accuracy, quality and relevance of information for strategic decision making.

Download the conference brochure here.

Regulation of Health Care Provision in England

The Kinds Fund has produced a very helpful 11 page briefing note on the regulation of health care provision in England.

From April 2009 the new Care Quality Commission will take over the work of three existing health and social care regulators – the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. The government is also introducing new arrangements for regulation of the market in health care.

This briefing examines the recent history of the quality and safety, financial and economic regulation of health care providers in England; describes the new regulatory machinery that is being introduced; and considers how the relationship between these different regulatory systems may develop in the future

Download the briefing here.

Audit Commission launches “intelligent resource” for PCT non-executive directors

The Audit Commission, in its latest issue of Health Update (Issue 20, November 2008), announces the launch of its intelligent resource for non-executive directors of Primary Care Trusts (PCTs).

The Commission describes the resource as ”a one-stop shop of useful documents and information that every non-exec should be familiar with. Some are Audit Commission publications and others relate to the HFMA, Healthcare Commission or Department of Health.”

The library is divided into three different categories for easy navigation including strategy and business development, financial health and performance, and governance and risk.

The resource can be accessed here.

Access the latest issue of the Audit Commission’s Health Update newsletter here.

Improving governance and accountability in children’s trusts

The Audit Commission has published Are we there yet? Improving governance and resource management in children’s trusts.

This report examined the progress local councils and their partners are making in developing children’s trusts. The report concludes that the ‘children’s trusts’ created by the government after the death of Victoria Climbie have been confused and confusing. Five years after the green paper Every Child Matters and eight years after the child’s death, ‘there is little evidence of better outcomes for children and young people’ resulting from the requirement that local areas in England set up arrangements to coordinate children’s services.

A third of directors of children’s services say that their partner organisations are ‘unclear’ of the purpose of children’s trusts, and the uncertainty is hampering their efforts to deliver better services. However the study did find that progress has been made in bringing professionals together, but sometimes by navigating around the ‘centrally-directed approach’. Local agreements worked better than external direction.

This report is all the more poignant given recent controversy surrounding the death of ‘Baby P.’ There is much in the report that can be used as learning that can be applied to the NHS.

For example, the Audit Commission has published a self assessment tool that children’s trust boards can use to assess their governance and accountability arrangements, as well as the way they manage resources. The key question areas in the self assessment tool for children’s trust boards to consider are:

1. How far does the children’s trust focus on improving outcomes for local children and young people?
2. How does the board oversee the effective use of resources?
3. What are the roles of the children’s trust partners in delivering improvement?
4. How does the board effectively consult, engage with, and involve key stakeholders?
5. How does the board support local capacity building and capability development?
6. How are good governance and the principles of public life demonstrated by the board?
7. How does the board manage risks and exercise proper controls?

Download the report and the self-assessment tool here.

The role of the Primary Care Trust board in world class commissioning – An opportunity missed….

The Department of Health (DH) has published guidance on the role of the Primary Care Trust board in world class commissioning.

This document aims to provide consolidated guidance on:

- the role and functions of the PCT;
- the role of the PCT board;
- the composition of the PCT board;
- the competencies and characteristics of a high-performing PCT board; and
- key sources of further guidance.

Healthcare Governance Review’s initial reaction to the document is that whilst it contains some useful information and guidance, the document falls into the usual Department of Health ‘trap’ of confusing governance with management. It is a great pity that the Department missed the opportunity of cross-referencing its own recently published document that sets out the essential characteristics of an effective board (click here for further information).

Sadly, Paul Stanton’s assertion about the DH governance ‘muddle and confusion’ still very much holds true.

Download a copy of The role of the Primary Care Trust board in world class commissioning here.

Action to improve proportion of black and minority ethnic members on NHS trust boards

According to the Health Service Journal (6 November 2008), the Department of Health (DH) is “working with the Cabinet Office to set a target for a public service agreement [on enforcing the proportion of black and ethnic minority (BME) managers in each trust]… and looking at how they’ll be set locally.”

DH director for equality and human rights Surinder Sharma apparently told HSJ the issue was being treated as a priority to make boards more representative of their local populations.

For further information, see the HSJ article here.

Debunking the myth about ‘command and control’ leadership and management

An interesting opinion article by Richard Knowles in the Health Service Journal (29 October 2008) attempts to debunk the pejorative view of ‘Comand and Control’ in the NHS.

He says that “Commonly held views about command and control are that it smacks of micromanagement, centralisation and everything else that is bad about those at the top telling everybody else what to do.”

He posits the alternate view that “Command and control can actually fit extremely well into models of leadership and management that seek to devolve authority and empower staff.”

To explore the true benefits of a Command and Control approach he looks at how Admiral Horatio Nelson, architect of one of Britain’s most celebrated naval victories, achieved what he did at the Battle of Trafalgar.

To read the full article, click here.

Health Committee Patient Safety Inquiry – evidence session, House of Commons, 20 November 2008

Health Committee 7 Millbank London SW1P 3JA healthcom@parliament.uk  020 7219 6182

10 November 2008 No 26 For Immediate Release

Patient Safety

The following evidence session has been arranged as part of the above inquiry:

Thursday 20 November 2008 at 10.00 am

Witnesses:

10.00 am Professor Richard Thomson, Professor of Epidemiology and Public Health, University of Newcastle and Professor Alastair Gray, Professor of Health Economics, University of Oxford.

11.15 am Mr Martin Bromiley, Chairman of the Clinical Human Factors Group, Ms Josephine Ocloo, World Health Organization Patient Safety Champion, and Mrs Clare Bowen.

Location: Wilson Room, Portcullis House

Further evidence sessions will be held in the New Year and dates announced in due course.

The sessions will be open to the public on a first come, first served basis. There is no system for the prior reservation of seats in Committee Rooms. It is advisable to allow about 20 minutes to pass through security checks. Committee rooms and timings are subject to change.

For further information on the Health Committee’s patient safety inquiry, click here.

Notable quote: NHS boards and organisational performance

“What difference do boards make? Connecting the structure, roles and behaviours of boards with evidence of impact on organisational performance is beset by theoretical difficulties and weak evidence, but it is worth the effort.”

Naomi Chambers, Health Service Journal, 7 Nov 2008 (Click here for full article).

Joseph Rowntree Foundation report on community involvement in the governance of local services

With increasing emphasis placed on the engagement of service users, citizens and communities in government policy, the Joseph Rowntree Foundation (JRF) has published a 70 page report that examines community involvement in the governance of local services, with an emphasis on the role of public officials. Community involvement in governance is defined as “community involvement in shaping local services and policies.”

According to the report, “The role played by public officials in community engagement has important effects on the extent to which community views can influence local services”

The report studies the experiences and views of public officials, comparing a local authority, a police service and a Primary Care Trust in Haringey, North London.

Specifically, the research examines:

- public officials’ perspectives on the purposes of community engagement, the different types of engagement mechanisms used, and the role played by community participants;

- organisational constraints and enablers of community engagement, including senior management support, resources, performance management systems, time frames and organisational culture;

- the informal practices and processes used by public officials to engage with the community and their attitudes and feelings towards it; and

- officials’ views about the extent of community influence and the factors which affected this.

 Download the report, Public officials and community involvement in local services, here.

In Ireland, the “HSE is placing clinical governance at the heart of its new structure”

The Health Service Executive (HSE) in Ireland is looking to improve patient safety and quality of care through putting clinical governance at the heart of the Irish health service’s new structure. So says a recent report by the HSE on a review of chest x-rays and CT scans reported by a Locum Consultant Radiologist at Louth Meath Hospitals from August 2006 to August 2007.

The review was prompted by a missed diagnosis in a small number of patients who later died from lung cancer.

The review found that 9 people in the care of Louth Meath Hospitals had their diagnosis of cancer delayed by some months as a result of radiological missed diagnoses. The delayed diagnoses had varying impacts on these patient’s care and treatment options, but included lost opportunities in relation to cure prospects, additional life-span and earlier palliative care. The delay in diagnosis led to worry uncertainty and distress for families and greatly reduced the time available to them to come to terms with the serious diagnosis and the impending death of their family member. In some cases this period of uncertainty prevented advance planning for and adjusting to the inevitable terminal phase of cancer. In the cases where a small chance of cure had been denied, by delayed diagnosis, the families concerned would have the added burden of trying to deal with that very difficult issue. This included the tragic impact on a family whose relative lost a major chance of cure for her cancer.

In response to the review, the HSE has initiated a project to enhance clinical governance in the radiological service in the north east hospitals group and therby improve patient safety and quality of care.

Download a copy of the review report here.

NHSLA publishes its evidence to the Health Committee inquiry into patient safety

The NHS Litigation Authority (NHSLA) has published, on its website, it’s evidence submitted to the House of Commons Health Committee.

The NHSLA provides a set of risk management standards specific to the risks faced by each type of NHS healthcare organisation i.e. acute hospitals, mental health & learning disability services, Ambulance Trusts and Primary Care Trusts, along with a set of standards for implementation by the independent sector covered under CNST when providing NHS care. Each set of standards incorporates organisational, clinical and health & safety risks. Separate clinical standards exist for organisations providing maternity services.

According to the NHSLA, “It is not possible to demonstrate a causal relationship between the introduction of the NHSLA risk management standards and assessments and improved patient safety, because of the complex environment of NHS care and the range of variables which would need to be considered. However, anecdotal evidence from those required to implement the standards, and the views of other stakeholders, suggest that they provide an effective framework within which to manage risks and thereby promote patient safety.”

The NHSLA’s evidence to the Health Committee can be downloaded here.

New website for Committee on Standards in Public Life

The Committee on Standards in Public Life is an independent public body which advises government on ethical standards across the whole of public life in the UK – including working in the NHS.

The Committee was responsible for establishing the following seven principles, which are enshrined in NHS governance guides:

1. Selflessness
2. Integrity
3. Objectivity
4. Accountability
5. Openness
6. Honesty
7. Leadership

Every 2 years the Committee publishes a public report on public that assesses public attitudes, expectations and perceptions towards the behaviour of those in public life.

Interestingly, the last report, in 2006, showed that only 43% of the public trusted senior managers in the NHS to tell the truth, compared to 93% trusting family doctors to do likewise. The next report will be published on 10 November 2008.

The Committee has a new website, which can be accessed here.