Healthcare Commission reports on patient and public involvement in service planning and improvement

The Healthcare Commission has produced a report on a national study of how well healthcare organisations engage local people in planning and improving their services. Key findings are:

- Patients and service users involved in the study generally felt they did not have enough say in their health services. They wanted more information about how to give their views and what changes are made as a result of their contributions. The report recommends trusts should strengthen the culture of being open and responsive with local people and give feedback on how their contribution has improved services.

- Problems were experienced when patients and service users are trying to make their views heard. Key themes included: poor communication; lack of openness; poorly designed local surveys and questionnaires; not enough opportunities to discuss views in an environment where they felt comfortable; no sense of NHS trusts building a relationship with them over time.

- One in four comments from patient groups on NHS trusts’ performance against the relevant core standard in the annual health check were negative. Most of these (80%) were about trusts failing to seek the views of patients and the public. About 50% were about how far, if at all, their views were taken into account.

- People’s views were not used routinely in planning and improving health services. Most trusts could provide some examples of using people’s views, but few demonstrated they routinely took account of them when planning and improving services. In addition, few organisations described any evaluation of their work with patients to find out whether it made a difference to people or services. The report recommends trusts should be able to demonstrate that people are influencing their major service and commissioning decisions.

- Some communities and groups are still ‘not heard’. Most trusts recognised they did not do enough to use the views of those in the poorest health or most in need of their services, and identified specific groups. Groups least likely to be heard include: black and minority ethnic communities, older people, people with learning disabilities, disabled people, children and young people. Healthcare organisations should increase efforts to reach these groups.

- Organisations should undertake checks on whether they, and their local patient and community groups, have the staff, skills and resources in place to involve people effectively in decisions about services.

The full report Listening, Learning, Working Together can be downloaded here.

Report identifies ’serious concerns’ about governance and procedural weaknesses in the awarding of a Managed Facilities Services contract at Whipps Cross University Hospital NHS Trust

Here’s a story we didn’t pick up on in November last year, but the lessons are still highly appropriate for NHS boards.

A report setting out the appointed auditor’s ’serious concerns’ about governance and procedural weaknesses in the awarding of a Managed Facilities Services (MFS) contract at Whipps Cross University Hospital NHS Trust (the Trust) was issued on 18 November 2008. The report, issued under Section 8 of the Audit Commission Act (commonly known as a public interest report) shows that the Trust failed to have adequate arrangements in place to ensure that it achieved value for money from this transaction.

Under the terms of this contract, signed in April 2006, the Trust contracted with a private sector supplier to outsource the management, servicing and replacement of NHS equipment in Theatres and Radiology, for a period of 12 years. As part of this contract, the Trust sold equipment with a book value of around GBP 3 million – GBP 3.5 million, received an initial payment of GBP 7.1 million (plus VAT) and committed to pay charges of GPB 3.2 million per annum for 12 years.

The report’s key findings were:

- The contract procurement, evaluation and approval process was undertaken over an inappropriately short timescale due to a misguided expectation that the contract would result in an accounting gain.
- The Trust’s selection of an ‘accelerated restricted’ procurement process was poorly judged, and it is highly questionable whether the Trust complied with EU rules around negotiation with bidders.
- The tender evaluation and shortlisting process was based on insufficient information, and was poorly documented.
- The Trust did not have adequate arrangements to ensure that the contract represented adequate value for money.
- The Trust has since reassessed the contract and believes that, whilst resulting in some operational improvements, it does not represent value for money.
- The GBP 7.1 million valuation of assets sold to the private sector supplier was significantly overstated.
- The Board did not have the skills or experience to understand and adequately challenge the risks associated with this complex transaction and placed too much reliance on the assurances provided by members of the executive team.
- The Board approved the MFS contract subject to SHA approval, but this was never provided unconditionally nor was there clarity on either side around what level of approval was required.
- The Board did not understand the role of external advisors relied upon in the approval process and as a consequence drew an inappropriate level of assurance from their involvement, even where the advisors’ limitations in scope were clearly set out in terms of reference.
- Significant contract amendments and side letters were negotiated after the contracts without Board approval, and the contract itself was backdated.

Download a copy of the report here.

Guide to measurement for patient safety improvement

The Patient Safety First Campaign has launched a ‘How to Guide’ for Measurement for Improvement.

The guide helps managers and clinicians demonstrate if changes are really improvement by providing them with the ability to test changes and measure the impact successfully. This is essential for any area that wants to continuously improve safety. To do this, the guide says you may only need a few specific measures linked to clear objectives to demonstrate that changes are going in the right direction.

The guide is based on previously published guidance from the US Institute for Healthcare Improvement and will be of great practical value to anyone in healthcare that wants to demonstrate safety and other types of improvement brought about by implementing changes.

Download the How to Guide for Measurement and Improvement here.

Clinicians and finance: Improving patient care

The Audit Commission, Academy of Medical Royal Colleges, Department of Health, the Healthcare Financial Management Association, NHS Institute for Innovation and Improvement and the Royal College of Nursing, have issued a joint statement highlighting the importance of clinicians’ involvement in financial management to further improve the quality of care for patients. The statement outlines the work of these organisations in supporting this ongoing campaign.

Download the statement –  Clinicians and finance: Improving patient care here.

Paul Stanton on the dilemmas of NHS governance

I’ve just spent a great two days with Paul Stanton at Villa Park Stadium in Birmingham (Ed.). No, we weren’t watching football. On Tuesday we were exploring governance in the NHS at the Health Service Journal’s(HSJ) ‘Fundamentals of NHS Governance’ event and yesterday we were at the HSJ’s first ‘Governance Challenge’  event, which was led by Paul (click here). 

Paul is an excellent ambassador for NHS governance.  

He has an online article in the HSJ published today that explores the ‘dilemmas of NHS governance.’

According to Paul, “There is continuing uncertainty about the meaning of the term governance. It is almost as often misused as it is used – not least by the Department of Health and others in the NHS who should know better……..Board governance”, says Paul, ”is the application of collective wisdom to complex and often profound uncertainty.

Read Paul’s full article, click here.

NHS: “Targets can kill”

An interesting article by Simon Caulkin in The Observer on Sunday 22 March posits the argument (quite rightly in the view of Healthcare Governance Review) that pursuing targets can be detrimental to patient care. Among other examples, he cites the case of Mid Staffordshire NHS foundation trust (click here.)

“Target-driven organisations,” he says, ”are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens.”

Read Simon’s Observer article here.

Related articles: Click here and here.

HSJ asks “Who let the standards fall so low at Mid Staffordshire” and finds that regulators need to question their own role

An article in the Health Service Journal (HSJ) today (26 March 2009) investigates what went wrong at Mid Staffordshire NHS foundation trust.

The article shows there are differing views and opinions on both sides of the fence. For example, a “senior acute director in the region” told the HSJ that “Mr Yeates [the then CEO] and his board were well respected and thought to be addressing the trust’s problems.” However, “This view is in stark contrast to the Healthcare Commission narrative, which devotes much attention to how Mr Yeates’ board [It's interesting to note that the board is referred to as the CEO's board!- Ed.] at best exacerbated, and at worst brought about, the problems it highlighted.”

The article also points to the fact that the regulators are being forced to question their own role. “In publishing its most critical report yet,” says the HSJ, “the Healthcare Commission has raised questions for its successor, the Care Quality Commission, for Monitor and for itself – about its own procedures.”

Read the full HSJ article here.

Looking at the problems at Mid Staffordshire NHS foundation trust through a Policy Governance lens

Caroline Oliver, a World authority on building high performing boards using the Carver Policy Governance model, has responded to the situation at Mid Staffordshire NHS foundation trust (see below) with a short article titled ‘Danger – Targets at Work’.

According to Caroline, the main problem in the NHS currently is that  ”assurance systems are often assuring the wrong things, by which I mean that they are assuring compliance with matters of means rather than ends.”  

Healthcare Governance Review believes that had the Mid Staffordshire board been focused on ends (i.e. organisational purpose) rather than fixated on various means issues, the outcome for many patients who allegedly died unnecessarily might have been very different.

Caroline states that “the work of boards in healthcare really matters.” Further, she believes that “the immediate hope for progress in terms of distinguishing ends from means lies with NHS boards who are the only people at local level who have the authority to require an ends focus and to hold themselves and their organisations accountable for the fulfillment of same. When boards define ends they are defining their organisation’s real bottom line – the criteria against which everything they do should ultimately be judged. When boards define ends they are providing meaningful leadership. Yes they need to ensure that everything about the organisation is legal, prudent and ethical, but without ever losing sight of the organisation’s purpose.”

You can read Caroline’s full article, Danger – Targets at Work, on her website here.

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.

Stafford Hospital ’scandal’: board members and managers who have not already left should “examine their consciences.”

Following on from the recent report into ‘appalling’ emergency care conditions (click here), Sir Ian Kennedy, Chair of the Healthcare Commission, is reported in the Sunday Telegraph today (Sunday 22 March, 2009) as saying that board members and managers who had not already left [Mid Staffordshire NHS foundation trust] should “examine their consciences”.

“Anybody who had any responsibility for leadership and management must ask how they allowed this place to get into the state where patients were dying,” he is quoted as saying in an interview with the newspaper.

Sir Ian Kennedy said it was clear that serious problems at the hospital were evident as far back as 2002, yet no action was taken by managers. He also criticised ‘bosses’ at the strategic health authority for failing to act.

The Sunday Telegraph has launched a campaign today for a series of measures to ensure that the crisis in Staffordshire is never repeated in the NHS. The Heal Our Hospitals campaign demands the establishment of an independent inquiry into the regulation and supervision of NHS hospitals.

The newspaper is also calling for:

- A review of hospital targets to ensure that they work to improve quality of care.
- Nurses to focus on patient care – not form-filling – as their central duty.
- Routine publication of comprehensive death rates for hospitals.
- Patients to be given a stronger voice in the running of hospitals.
- Assurance that senior hospital staff will not be rewarded for failure.

 Read the full Sunday Telegraph article here.

In ‘God’s country’, even His clerics must observe information governance rules regarding patient confidentiality

An unholy row appears to have broken out in Scotland between the Catholic Church and NHS Greater Glasgow and Clyde Health Board after the Board recently ended the practice of giving priests and ministers access to patient lists on the grounds it breached patient confidentiality.

According to an article in the Sunday Herald today (22 March 2009), “Clerics in the Glasgow region used to have the right to find out whether their parishioners were being treated in hospital. However, the health board has revised its rules on accessing lists because of fears it may breach the rights of patients. The board’s information governance officer instructed health record staff in December 2008 not to pass on ward lists. Health chiefs believed the practice may have contravened the Data Protection Act 1998.”

The full Sunday Herald article can be accessed here.

Royal Cornwall Hospital report finds ‘corporate [board] failure’, but authors appear to lack knowledge of ‘governance’

An independent ‘review of management and governance’ at Royal Cornwall Hospitals NHS trust has accused the CEO and the board of ’serious failures’ including failing to “sufficiently follow the spirit of the codes of conduct for NHS board and managers.”

The review was carried out after a similar review of Bromley Hospitals NHS trust (click here). The CEO of Bromley was the current (suspended) CEO of the Royal Cornwall Hospitals.

The CEO, John Watkinson, comes in for particular criticism in the Royal Cornwall report, which states that “Some interviewees commented on the Chief Executive’s unprofessional and inappropriate use of humour, how he would make offensive comments about people and how dismissive and aggressive he would be when challenged. A dominant culture at team meetings emerged which was described as ‘jokey’ or ‘laddish’. As a result a number of senior managers and directors outside the core team at times felt unable to challenge proposals or behaviours because they were feared of ridicule or worse, retribution.”

Whilst the report appears to present a robust review of management, Healthcare Governance Review feels that the same cannot be said of the authors’ approach to governance.

For example, recommendation 101.1 states that ”The Trust board should decide, for example by benchmarking, whether its management resource is sufficient and if so correct the position especially at divisional level.” Do the author’s genuinely believe the board’s role is to get management sorted out at any level below the CEO? Boards are supposed to govern, not manage!

Download the full report here.

UPDATE 28 March 2009: The Health Service Journal has written an interesting article on suspended Royal Cornwall CEO John Watkinson. Click here.

Healthcare Commission publishes its ‘legacy report’

The Healthcare Commission, which is being replaced on 1 April 2009 by the new Care Quality Commission, has published a document describing its experiences over its 5 year life. Specifically, the publication:

1. Sets out the background to the establishment of the Healthcare Commission.
2. Summarises the approach to information-led, risk-based regulation taken by the Commission.
3. Considers the contribution that regulation of healthcare has made to better outcomes and quality of care for people.
4. Reviews the lessons that have been learned about the approach to regulation, and the implications for future regulatory models.
5. Highlights the lessons from regulation for the healthcare system as a whole.

Download the publication The Healthcare Commission 2004-2009: Regulating healthcare – experience and lessons here.

Department of Health publishes report on improving clinical governance in the NHS

Here at Healthcare Governance Review we thought that ‘clinical governance’ had fallen out of favour at the Department of Health (DH), what with no real mention of it in Lord Darzi’s approach to improving quality in the NHS.

On 20 March 2009, however, the DH published a major report Tackling Concerns Locally, supported by several ’subgroup reports including one by the ‘Clinical Governance subgroup’. 

Tackling Concerns Locally, together with its supporting reports, sets out the principles of best practice on how local systems for clinical governance could be strengthened to promote continuous improvement in the quality of care and enable healthcare organisations to identify and deal with those healthcare professionals whose performance, conduct or health could put patients at risk.

According to the report of the Clinical Governance subgroup, “Boards have a corporate duty to ensure that the processes for clarification and investigation of concerns about performance, conduct and health are carried out in a consistent and fair way and to ensure that the individuals involved in the process are appropriately trained, supported and resourced to do so.

The Clinical Governance subgroup also looks at clinical governance in a wider context. “Good clinical governance and patient safety” they say ”is part of a culture that is led by the Board but implemented by the actions of individuals and is the responsibility of all of those within the organisation…….Where an organisation has strong governance processes, the whole clinical governance spectrum can be seen to be working effectively to both assure the quality of individuals working within the system and to ensure that poor performance is identified and managed appropriately.”

They go on to say that “The Board and its leaders are accountable for the actual and potential issues that affect the quality of the services provided and will soon be required to provide an annual ‘quality account. The Board should strive to build and maintain such a supportive clinical governance culture and have processes that are monitored to assure itself that the healthcare organisation is identifying, investigating and taking action to deal with and learn from patient safety and quality concerns.

In support of their assertions, the Clinical Governance subgroup helpfully specifies, in chapter 2 of their report,  the generic ‘components’ of a clinical governance framework in all healthcare organisations in relation to Tackling Concerns Locally. The components are arranged into the following ‘dimensions’ of clinical governance:

- Corporate, clinical and information governance of organisation
- Culture: leadership, teamwork and communication
- Patient safety, risk management and incident reporting
- Feedback and involvement from users and stakeholders
- Quality improvement and service development, focus on clinical and service outcomes
- Use of information
- Educational and supportive ethos, effective appraisal systems supportive ethos, effective appraisal systems

Download the main report Tackling Concerns Locally, together with the clinical governance and other sub group reports here.

Access background information on the Tackling Concerns Locally project here.

Report into “appalling” emergency care at Mid Staffordshire NHS foundation trust finds board’s attention not focused on patients

The Healthcare Commission has released a report today into higher than expected death rates among patients admitted as emergencies. About 400 more people died at Stafford Hospital between 2005 and 2008 than would be expected, the Healthcare Commission said.

The report criticises Mid Staffordshire NHS Foundation Trust for “significant failings in emergency healthcare, leadership and management.” The report states that there were deficiencies at “virtually every stage” in the care of people admitted as emergencies.

An analysis of the trust’s board meetings from April 2005 to 2008 found discussions were dominated by finance, targets and achieving foundation trust status. There was little evidence that poor standards of nursing care were identified and discussed.  

According to the Healthcare Commission, “Trusts, from the board to the ward, need to have reliable comparative information on care, including rates of mortality and other outcomes, and to ensure that patients receive proper care when admitted as emergencies.”

Read the Healthcare Commission Press Release and its investigation report here.

Read the Mid Staffordshire NHS foundation trust response to the Healthcare Commission report here.

USA report into ‘Competency-based governance’

The Center for Healthcare Governance, an American Hospital Association (AHA) affiliate, has released a report titled Competency-Based Governance: A Foundation for Board and Organizational Effectiveness. The report includes recommendations for hospital boards of trustees, educators and researchers to better understand and practice competency-based governance.

According to the report, any effective board members should be competent in at least 14 areas: accountability, achievement orientation, change leadership (defined as: “maintains an eye on strategic goals and values during the chaos of change”), collaboration, community orientation, information seeking, innovative thinking, complexity management, organizational awareness, professionalism, relationship building, strategic orientation, talent development and team leadership.

The report is available for sale here.

The report is mentioned in an interesting article titled ‘raising the bar for boards’ on www.modernhealthcare.com (click here for article – registration required).

New NHS complaints regulations published

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (SI 2009 309) have been published.

These regulations come into force in England on 1st April 2009. They make provision for complaints made on or after 1st April 2009 in relation to local authority social services and the National Health Service. They replace the current NHS complaints regulations.

Access the new regulations here.

See also the new guidance on complaints issued by the Department of Health. For further information click here.

Notable quote: Organization complexity and perceptions of risk

“……..risk, rather than being a linear, objective and manageable concept, is actually created, re-created and constructed. The construction of risk takes place within the constant sense-making that occurs in organizational life. Risk is, therefore, a complex phenomenon, and one that cannot be fully subjected to objective and rational analysis. Indeed, because risk is created through the ways in which reality is constructed by members of the organization, such risks are not ‘real’ but rather based on assumptions and perceptions.”

Steve McKenna, CEO, Singapore Institute of Commerce
For further information, click here.

Update on ‘How do NHS boards get their assurance?’ Audit Commission report to be published in April

Healthcare Governance Review alerted readers last July to an Audit Commission study on board assurance assurance (click here).

This study, which focuses on the evidence provided to boards of NHS trusts and foundation trusts to enable them to make their core standards declarations and the accounting officer to sign the Statement on Internal Control (SIC), is nearing completion.

A draft of the report has gone out to stakeholders for consultation and the report is due to be published in April. They key point is whether boards are getting the assurance they need about the trust, its performance and the management of the risks it faces.

The review involved visits to 15 NHS trusts and foundation trusts as well as reviewing existing guidance and work previously carried out on the subject.

The recommendations cover the following areas:

- the setting of strategic objectives
- the role of internal audit in providing assurance)
- the identification and evaluation of potential sources of assurance
- the content of the SIC and the head of internal audit opinion
- the quality of performance data

For further information about the study please contact Andy Lund on 0844 798 2172 or a-lund@audit-commission.gov.uk

ICSA publishes its annual survey on board performance evaluation of UK Listed Companies

The Institute of Chartered Secretaries and Administrators (ICSA) has published its survey on board performance evaluation of UK Listed Companies. ICSA is the professional organisation that trains and supports company secretaries and is a leading authority on corporate governance.

The annual review looks at how the largest listed companies in the UK have chosen to evaluate the performance of their board, audit, nomination and remuneration committees and the individual board directors in line with the Combined Code. As in previous years, the survey reproduces from the annual reports of the 200 largest UK companies (as at December 2008) those passages which address the conduct and outcomes of the evaluation processes relating to the company’s board.

Healthcare Governance Review believes there may be some lessons or items of interest for healthcare boards resulting from careful consideration of the ICSA survey.

In the 2008 reporting season, 21 per cent of the 200 companies covered by the report have elected to undertake some form of externally developed or managed evaluation process. This compares favourably with last year’s figures of 16 per cent. However, several companies engaged the services of a search consultant or their current audit firm to undertake the evaluation. Given the potential for conflict of interest, this raises the question as to how rigorous these reviews actually were.

Simon Osborne, ICSA’s Joint Head of Board Evaluation comments: ‘ Our most recent survey shows that more companies are embracing externally driven evaluation but there is still apprehension about ‘exposing dirty linen’ to an outsider even though a reputable evaluator will always respect client confidentiality. However, more widespread use of external valuation will no doubt be driven by investors who will be looking for hard evidence of well-run boards in an uncertain economic climate’.

The full survey can be downloaded here.