Governance arrangements to support PCT provider committees

The Department of Health (DH) and NHS Appointments Commission have issued guidance “ intended to help support PCT provider committees implement strong robust governance arrangements in order to deliver the transformation of community services.”

The guidance contains the following sections:

1 Good Governance for Community Services – This section sets out the scope of this guidance and provides the context for good governance within community services

2 Provider Committee -  This section sets out the key principles that should underpin recruitment of the independent members to Provider Committees, the advantages and disadvantages of the various recruitment options, the suggested appointments process and the roles and responsibilities of the independent members of the Provider Committee

3 Terms and Conditions for PCT Non-Executive Directors on Provider Committees – The terms and conditions for PCT non-executive directors serving as independent members of the Provider Committee are set out, including current arrangements for remuneration, time commitment, corporate responsibility and suspension and termination

4 Terms and Conditions for Independent Lay Members of Provider Committees - The terms and conditions for members of the Provider Committee appointed as independent lay members are set out, including arrangements for remuneration, time commitment, corporate responsibility and suspension and termination

5 Governance Good Practice – This section provides key principles and good practice around establishing robust governance arrangements for the operation of the Provider Committee, including terms of reference, delegation of powers, reporting arrangements, use of sub-committees and managing conflicts of interest

6 Resources – A list of relevant resources and guidance is provided

Download the guidance Transforming Community Services – Governance Arrangements to Support PCT Provider Committees together with a covering letter from David Nicholson, NHS chief executive, here.

Audit of organ retention and post-mortem practices in Irish hospitals points to deficiencies in clinical and corporate governance

The Health Service Executive (HSE) in Ireland has published two reports relating to retained organs and post-mortem practices in Irish hospitals.

The first is an independent national audit of retained organs and post-mortem practices in Irish hospitals. Organs or tissues are sometimes removed and retained as part of a post-mortem examination, primarily to allow for analysis of the cause of death. In hospital post-mortem services, this follows a detailed information and consent process with families. Consent processes underwent significant change and improvement following public outrage in 1999 and 2000 about post-mortem and organ retention practices in the UK and in Ireland.

The national audit was led by Ms. Michaela Willis MBE, a former member of the Human Tissue Authority in the UK and former member of the Retained Organs Commission, which previously oversaw similar audits in England. Ms Willis conducted an independent audit of currently retained organs in the State both pre and post 2000 to assist the HSE in identifying areas of good practice and highlighting areas for improvement.

The audit found many examples of good practice in clinical governance relating to post-mortem services. In the course of the audit, however, specific issues arose at the Rotunda Hospital, Dublin, which required a separate investigation and report. This was undertaken on behalf of the HSE by a team chaired by Mr. Ian Carter, Chief Executive, St. James’s Hospital.

The Carter report found a range of issues at the hospital, which included weakness in consent policy and documentation, variations between the terms of the consent given by families and the post-mortems carried out, delays in carrying out examinations and delays in implementing family instructions for respectful burial of organs or tissues.

The report found that the issues at the hospital arose from individual professional practice, poor post-mortem systems and processes and weak management and governance oversight.

The Board of the Rotunda have assured the HSE that the clinical and corporate governance of post-mortem practice have been significantly strengthened in response to the investigation.

Download the audit and Carter reports here.

Progress report on ‘Review of the Effectiveness of the Combined Code’, plus launch of second consultation

The Financial Reporting Council (FRC) has published a progress report on its review of the effectiveness of the Combined Code, together with copies of all first stage consultation responses received.  At the same time it has launched its second consultation on the subject.

Of particular note in the report is the statement by the FRC that “There is a recognition that the quality of corporate governance ultimately depends on behaviour not process, with the result that there is a limit to the extent to which any regulatory framework can deliver good governance.”

The FRC would welcome any additional comments or other evidence on the issues identified in its progress report by 9 October 2009. If you have already given your views on these issues as part of the initial consultation, there is no need to do so again as those comments will be taken into account when assessing the overall evidence gathered as part of the review.

Comments should be sent by e-mail to codereview@frc.org.uk or by post to the address provided in the progress report.

Download the progress report here.

Responses to the 2009 consultation on the review of the Combined Code can be accessed here.

Trust chair resigns in the face of NHS “bullying” and “obsession with targets rather than safety”

As reported in the Health Service Journal today (27 July 2009), the chair of an acute NHS trust has resigned, calling on NHS chief executive David Nicholson to investigate the behaviour of East Midlands strategic health authority in pressurising him to meet access targets.

David Bowles, chair of the United Lincolnshire hospitals trust, says he refuses to work in a system which he says has not learnt the lessons of Mid Staffordshire and which has lost sight of patient safety issues, and that it is his duty to resign and bring attention to that.

His stance has been supported by the other non executives at the trust, who have also written to Mr Nicholson asking him to investigate.

In an email, seen by HSJ and attached to their article (see below), to shadow health minister Mark Simmonds, who is MP for neighbouring Boston and Skegness, Mr Bowles said: “What I have witnessed from outside the trust appears to be a substitution of bullying for performance management and an obsession with targets rather than safety.”

“It is often said that the culture in the NHS, particularly at the more senior levels, is not to listen, not to understand, to avoid responsibility, and to blame others.

“In the interests of patient safety I can not and will not give the unequivocal assurance that the SHA is seeking on non-emergency targets especially at a time when the Lincolnshire health economy is out of control with the highest ever level of weekly emergency admissions this month.”

He added that he had had allegations from staff about bullying by NHS staff from outside the trust.

Read the full HSJ article, along with Mr Bowles detailed e-mail to Mark Simmonds, here.

Walker report calls for periodic independent board evaluation

Sir David Walker has published his interim review of corporate governance in the UK financial system. He was appointed by the Prime Minister and his work is being undertaken, and published, under the auspices of HM Treasury, consequently Healthcare Governance Review believes that ‘The Walker Review of Corporate Governance’ will eventually impact NHS boards.

Sir David believes that the UK Combined Code on Corporate Governance (which forms the basis of Monitor’s Code of Governance for NHS foundation trusts) remains fundamentally ”fit for purpose.”

He report, however, highlights the following opportunities for enhancing board effectiveness:

- the key emphasis for the future, he argues, should be on improving board behaviour, particularly in relation to non-executive directors challenging management, rather than on introducing a new governance framework.

- board composition should give greater regard to relevant expertise rather than the fulfilment of formal independence criteria.

- the time commitment required of non-executive directors, and the implications of this for the number of board positions that should be undertaken by one individual, should be carefully considered.

- consideration needs to be given to the pivotal role played by the Chair in the effectiveness of the board.

- non-executive directors should be provided with greater in-house support in order to fulfil their role.

- a process of independent board evaluation should be undertaken by external evaluators every 2-3 years and disclosed in the annual report.

Sir David’s interim report and associated information can be downloaded from HM Treasury here.

Readers might also like to read the short blog piece from Miles Templeman at the Institute of Directors, here.

Notable quote – boards and managers

“Boards and Managers……do not own the business but sell their skills to act on behalf of the owners, and do not produce personally but are indispensible in making others produce through motivation.”

Cultural constraints in management theories. New management reader. Routledge, Open University, 1996

NHS boards – preparing for Quality Accounts

The Department of Health (DH) along with the Care Quality Commission, Monitor and NHS East of England, has written to all trusts to update them on overall progress on Quality Accounts to date; and to encourage them to make their local preparations needed before publishing their first statutory Quality Accounts in (subject to the legislative process) June 2010. The DH says they ”will write again in the autumn with our consultation on the final shape of Quality Accounts.”

Annex A to the letter sets out a summary of the engagement process DH has undertaken to date. In addition, NHS foundation trusts and NHS organisations in NHS East of England have produced Quality Reports for 2008-09 which have provided “a valuable foundation for our [DH] thinking on Quality Accounts.” There is a link in Annex A to some examples that Foundation Trusts have put together. These – and other examples – will, according to DH, be evaluated, and the findings published later this year, as part of a “best practice toolkit” they are developing. This will also, apparently, include guidance on issues such as stakeholder engagement, audit, and board assurance, details of which are set out in Annex A.

From the findings so far, the broad content of Quality Accounts is, according to the DH,  likely to contain the following:

• a statement setting out how the Board has assured itself about the quality of the services offered by the organisation;

• an outline of your organisation’s Quality improvement priorities;

• information relating to locally chosen and relevant indicators on the quality of services provided in your organisation;

• a small amount of nationally determined content – this is likely to include for example, evidence of your current CQC registration status, and relevant findings from CQC’s periodic and special reviews;

• a description of how you decided what to include in your Quality Account, including who has been involved in its design, and how you took account of the views of the views of patients, the wider public and the regulators.

There was, according to the DH, also a very strong feeling that Quality Accounts would have greatest impact if they were readily accessible to the public.

Download the letter and associated annex here.

NHS boards and swine flu – the situation in England

On 2nd July the Department of Health (DH) wrote to NHS organisations setting out guidance for managing the swine flu pandemic.

Despite the fact that swine flu (H1N1) appears to be of little real threat to the majority of the population, nevertheless the demands place on the NHS by those with, or suspected to have, swine flu are likely to be immense.

The DH guidance Swine Flue Pandemic: From containment to treatment – Guidance for the NHS sets out a number of requirements for NHS boards, viz:

- each NHS Board should appoint a full time director level lead dedicated to flu preparedness and resilience with immediate effect. This can be a single individual or shared between directors but must provide visible, full-time, senior leadership and ensure a well-resourced team on this issue through the months ahead

- each NHS Board is requested to take reports on progress towards their readiness assessment against the Department’s HR and Surge guidance to their July and August meetings

- each NHS organisation takes part in the September nationally devised and SHA and HPA-organised resilience testing and exercise programmes to validate Pandemic Flu Plans and Winter Readiness Plans. Board level attendance, including from NHS CEs, is expected at these events

- each strategic health authority (SHA) Board should assess the robustness of NHS organisational and local system Flu Pandemic Plans and sign off that assurance on behalf of the Department of Health

- each PCT Board should demonstrate visible leadership through effective dialogue with local LMCs and individual practices.

Download the full DH guidance Swine Flue Pandemic: From containment to treatment – Guidance for the NHS  here.

Improving clinical governance in Out of Hours services – ECRI Institute’s INsight Systems Assessment

Out of Hours (OoH) services now provide patient care for 70 per cent of the patient week. With this comes the clinical governance challenge to ensure that the quality of service remains as high as ever, having reduced any exposure to unnecessary risks. Recent tragic events in the provision of Out of Hours services remind us that this is often a very difficult and ever present challenge for the commissioners and providers of these services.

This is why the ECRI Institute, a major non-profit health services research agency, and sponsor of Healthcare Governance Update, has developed its dedicated INsight ™ Systems Assessment Programme for the use of Out of Hours services. An INsight system assessment is a multidimensional organisation-wide patient safety, risk and quality systems assessment. It helps an organisation determine if its systems are robust, reliable and effective enough to support its governance responsibilities to ensure quality and meet the national standards.

More information about INsight System Assessment for Out of Hours Services is provided here.

ECRI Institute Alerts Tracker launched in primary care

ECRI Institute, a non-profit health services research agency and sponsor of Healthcare Governance Update, has recently launched in primary care its Alerts Tracker web based system for tracking action on safety alerts. Although the system has been widely used by secondary care providers in the UK and around the world for many years, it has recently been modified for use in primary care.

In launching Alerts Tracker for primary care, Dr David Watson, ECRI Institute Vice President UK & Europe, explained that primary care has just the same needs to ensure that the loop is closed effectively once a safety alert has been notified. Also, in ECRI’s experience it’s one thing to receive a safety alert but to get it into the right hands and get the necessary assurance that action had been taken was quite a different matter. He went on to say that many PCTs were seeing the advantage of the system as it reduced the need for lots of administrative time in chasing up action.

For further information click here –  Alerts_Tracker_HGR

ACCA calls for enhanced training for board members of NHS organisations

The induction and ongoing training available to those responsible for governance in NHS bodies should be evaluated and enhanced to ensure that it meets members’ needs more effectively, says ACCA (the Association of Chartered Certified Accountants) in its report, understanding governance in the NHS, which was recently launched in Westminster.

The report is based on second year results from a three year research project undertaken in collaboration with the Department of Health. Dean Westcott, ACCA vice-president and chief financial officer of West Essex Primary Care Trust, said of the report: “Its findings acknowledge that non executive directors, while widely regarded as valuable in fostering effective corporate governance practice, have insufficient time to fulfil their role properly and are concerned about effectiveness of available induction and training programmes.”

Julia Rudrum FCCA, author of the report and past chair of ACCA’s health panel, said: “The survey of chairs, chief executives and directors of finance of all NHS organisations confirmed that board members were taking their responsibilities seriously and recognising the need for good governance. But while broadly supporting the guidance issued to date from the Department of Health to provide a framework for developing good governance, the report highlights that knowledge gaps remain and a certain level of confusion exists regarding just what good governance is.”

 Julia Rudrum concludes: “ACCA believes that a clear, principles based corporate governance guide that is useful to all users, but that recognises organisational variations, should be produced to enhance and consolidate existing publications. We also recommend that induction and ongoing training for board members is evaluated to ensure that it is co-ordinated and effective, but that it is also enhanced to meet members’ needs more successfully.”

The report Understanding governance in the NHS – Year 2 can be downloaded here.

Click here for information on the original ACCA Year 1 report.

Non-executive director development programme for existing and aspiring NHS foundation trusts

Manchester Business School, in association with GoodwinHannah Ltd, have developed a residential programme to enhance the contribution non-executives make to their boards. The programme is fully endorsed by Monitor and the NHS Institute for Innovation and Improvement.

The programme is an integrated three day residential event costing £2000 which builds the expertise of directors in four key areas: finance; strategy; clinical quality and organisation culture.

Seven NED competencies will be developed: knowledge of board and role; group decision making orientation; conceptual thinking; communication; clinical performance; board dynamics; and understanding of the health system.

For further information, click here.

“Efficient use of resources and good quality services go hand in hand” – new finance guide for doctors

The Audit Commission and Academy of Medical Royal Colleges have published A guide to finance for hospital doctors.

In the publication, they state that ”there are many examples where clinicians have led change and improved services, through taking greater responsibility for managing the money available to them. This is not about focusing on cost and cost alone, but how best money can be used to improve the quality of care, combining operational and clinical effectiveness. Efficient use of resources and good quality services go hand in hand.”

Healthcare Governance Review believes that the guide, whilst written for doctors, may be of interest to board members and managers.

Download A guide to finance for hospital doctors here.

Health Care Risk Report Vol 15 Issue 8 July/August 2009

Many of us look “across the water” for patient safety expertise, but as John Tingle explains in this month’s edition of Health Care Risk Report (HCRR), all is not well in the USA. The US Government has said that patient safety is declining, while consumers have given healthcare a “failing grade” on patient safety. Do we have a chance to do better over here?

 Also in the July issue of Health Care Risk Report : 

- The case of a young boy who was left disabled by meningitis and whose family secured for him a £5.5m payout;
- The failure of an attempted prosecution of the owners of a care home where 14 elderly residents died in a fire;
- How the National Patient Safety Agency plans to improve the way the NHS picks up and deals with serious incidents, by its chief executive Martin Fletcher;
- How airline pilot Martin Bromiley is helping the NHS to change its ways following the death of his wife during an attempted operation;
- The role that the Care Quality Commission is going to play in your working life;
- Risk management and “positive risk-taking” in mental healthcare;
- The difficulties of training staff to evacuate patients in an emergency; and
- Staff absenteeism levels in a flu pandemic.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

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.

Health Committee publishes patient safety report

The House of Commons Health Committee has published it final report on patient safety, extending to 120 pages.

Not surprisingly, they criticise the the NPSA’s National Reporting and Learning System as being “limited in its effectiveness” and note that the system does not collect root cause information – a key feature of the design of the System as set down in 2001 in the Department of Health’s Building a safer NHS for patientspublication. The NPSA was established in June 2001, which means that 8 years later the NPSA still has not delivered an effective national reporting and learning system.

NPSA Chief Executive, Martin Fletcher, is quoted in the Health Committee report as saying that ”an undertaking of this scale was a lot more complex than anybody had perhaps at first realised. You have to remember that when this system was set up five years ago it was the first of its type in the world.” Healthcare Governance Reviewfundamentally disagrees. We had the skills, we had the people and we had the technology. Much of what needed to be done had been demonstrably done prior to establishing the NPSA Sadly, the wrong people were put in charge and the rest is history. It is, perhaps, a sobering thought to consider that in the 8 years that the NPSA has failed to get its act together on national reporting and learning, many, many patients will have suffered needless harm or death.

CLINICAL GOVERNANCE

The report appears to be critical of clinical governance. It states at para. 289 that “Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services. The concept of clinical governance may be to blame for spawning a structural approach, focused on processes rather than on the actual state of frontline services.” The fact that the report seems also to be criticising boards for addressing governance issues (i.e. the board performing its proper role!) might indicate that the Health Committee fundamentally failed to understand the concept of governance!

RECOMMENDATIONS FOR NHS MANAGERS AND BOARDS

Readers might be particularly interested in the recommendation made in the report for managers and boards. They are:

- “There is disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust. While other Boards are not failing as comprehensively, there is substantial room for improvement.

- Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services. The concept of clinical governance may be to blame for spawning a structural approach, focused on processes rather than on the actual state of frontline services.

- Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject. There is a case for providing specialist training in patient safety issues, particularly to non-executives, to help them scrutinise and hold to account their executive colleagues. We agree with [the] suggestion about giving one non-executive member of each Board specialist training, to allow them to take particular responsibility for it. The example of Luton and Dunstable Hospital in having committees of the Board of Directors to Patient Safety look specifically at patient safety and patient experience should be recommended to all Trust boards.

- Patient safety must be the top priority of Boards. In order to fulfil their duty to ensure “that the quality and safety of patient care is not pushed from the agenda by immediate operational issues”, patient safety should without exception be the first item on every agenda of every Board.

- We commend to NHS organisations the measures piloted as part of the Safer Patients Initiative to ensure that Boards maintain safety as their foremost priority, namely

• implementing tried and tested changes in clinical practice to ensure safe care;
• banishing the blame culture;
• Providing the leadership to harness the enthusiasm of staff to improve safety;
• changing the way they identify risks and measure performance, by using information about actual harm done to patients, such as data from sample case note reviews.

We strongly urge the adoption of these throughout the NHS.

- In addressing the blame culture, we recommend that Trusts use means such as the Texas Safety Climate Survey to measure and monitor how far staff feel confident about being open and reporting incidents.

- We strongly endorse the DH’s view that no Board in the NHS should always be meeting behind closed doors. We urge the Government to legislate as necessary to ensure Foundation Trust Boards meet regularly in public; the public should only exceptionally be excluded.

- Many healthcare workers remain fearful that if they are open about harm to patients they will be unfairly blamed for causing it; and that if they whistleblow they will be victimised. Where information is available about incidents, it is too often not used to make lasting improvements to services. We have insufficient evidence to comment on the adequacy of statutory protection for whistleblowers. However, the information we have received indicates that the NHS remains largely unsupportive of whistleblowing. We recommend that the DH bring forward proposals on how to improve this situation and that it give consideration to the model operated in New Zealand, where whistleblowers can complain to an independent statutory body. We recommend that Annex 1 of the Health Service Circular, HSC 1999/198, “The Public Interest Disclosure Act 1998—Whistleblowing in the NHS” be re-circulated to all Trusts for dissemination to all their staff as a matter of urgency.

- Regarding Mid-Staffordshire Trust, we are unconvinced of the case for a full public inquiry into the Trust, given the work that has already been done by the Healthcare Commission, Professor Sir George Alberti and Dr David Colin-Thomé, and the likely further Patient Safety disruption to the Trust. However, we do see merit in the idea, recommended to us by the Royal College of Nursing, of holding hearings in private to allow members of staff to give evidence confidentially to discover how the state of affairs progressed so far without detection by the Trust Board. As this would look at the past and involve those in post in previous years, it would not impede the process of improvement and the rebuilding of confidence in the hospital. Although held in private its findings should be made public with protection of individual witnesses as appropriate.”

The full report Patient Safety Sixth Report of Session 2008-09, Volume I- Report, together with formal minutes can be downloaded here.

Notable quote: Management Vs (clinical) governance

“The relationship between the governing body and the front line is in essence clinical governance……..management is about running the business, governance is about seeing it run properly.”

Adrian, A (2000). Clinical and corporate governance – salvation or just jargon? Australian Nursing Journal Vol 17 Issue 10

NPSA issues seven patient safety questions for board members

The National Patient Safety Agency (NPSA), in association with the NHS Confederation and NHS Appointments Commission, has published a factsheet that includes a list of seven questions, with supporting guidance, that might usefully be asked by NHS board members to help ensure as part of their role in ensuring the care given in the organisations they govern is safe and risks are reduced.

The seven questions are:

Question 1: Does everyone understand the importance of patient safety?

Question 2: Do we really have an open and fair culture?

Question 3. Are we actively encouraging reporting of incidents?

Question 4. Do we get the right information?

Question 5. Are we always open when things go wrong?

Question 6. Do we learn from patient safety incidents?

Question 7. Are we actively implementing national guidance and safety alerts?

The full factsheet can be freely downladed here.

NHS CEOs: ‘Bold and Old’ – essential board reading from Hoggett Bowers

Executive Search company Hoggett Bowers has published a report on a survey of NHS organisations in England about the length of tenure of their present and immediate past NHS CEOs and Directors of Finance (DoFs). The authors also spoke with a number of Chairs, senior executives, human resource directors and senior clinicians. They hope “that the key messages that have emerged through [the report] will help Chairs, NEDs and CEOs think about how they can work together” and “to stimulate discussion about some of the real challenges facing Boards and senior teams.”

The Health Service Journal reported (HSJ – 18 June 2009), based on the Hoggett Bowers report, that “The “startlingly” high turnover of NHS chief executives and finance directors is discouraging trusts from making the bold decisions needed during an economic downturn.”

The report states that “‘It is highly desirable that effective CEOs remain in an organisation for at least five years. This allows shared purpose to be potentially developed. This flies in the face of David Nicholson’s (CEO of the NHS in England) assertion that “We find it very difficult to recruit people who want to be chief executives – the average time they spend in post is just 700 days.”

Given the current economic climate, this is a report that every CEO and Chair should read. Ideally, either the full or a summary of the report should be shared with all board members leading to a discussion around local implications.

The report – NHS Chief Executives ‘Bold and Old’ – can be freely downloaded here.