House of Commons Health Committee ‘Special Report’ on Patient Safety

The Health Committee has published a ‘special report’ on patient safety relating to the Committee’s patient safety report published in July 2009 (click here).

The Government responded to the patient safety report on 13 October (click here).

This special report sets out the responses to the patient safety report  by the Care Quality Commission and Monitor. It also contains a response by Professor Sir Ian Kennedy (formerly chair of the Healthcare Commission) and a reply to his response from the chairman of the Health Committee.

Of particular interest in the report is Monitor’s responses to various issues around boards highlighted in the original patient safety report.

Download the 27 page ‘special report’ Patient Safety: Care Quality Commission, Monitor, and Professor Sir Ian Kennedy’s Responses to the Committee’s Sixth Report of Session 2008-09 here.

“Assessing board effectiveness should be a required component of the annual work programme for all NHS boards”

The Department of Health has published the summary findings of Neil Goodwin’s review of allegations of bullying and harassment of the United Lincolnshire Hospitals NHS trust by the East Midlands Strategic Health Authority (see previous post here).

The review found “no evidence” to support the claims against East Midlands Strategic Health Authority (SHA). However, concerns have been raised about the independence of Neil Goodwin, a former SHA chief executive (click here).

According to Mr Goodwin “Given the increasing pressures on NHS leadership and management that will result from the impact of the economic downturn on public services there is the possibility of firm performance management being interpreted as bullying or harassment.”

Key recommendations made by Mr Goodwin’s relate to improving the performance of board members and boards. In particular, he recommends that “Assessing board effectiveness should be a required component of the annual work programme for all NHS boards and the results included in performance management and regulatory assessments.”

Read the summary findings of Mr Goodwin’s report, along with NHS chief executive David Nicholson’s response here.

Charity Commission disputes Department of Health ruling on NHS charities’ accounts

According to an article in ThirdSector (27 October 2009), The Charity Commission appears to be heading for a showdown with the Department of Health (DH) over accounting procedures for NHS charities in England and Wales.

Senior Department of Health official Janet Perry has told health authorities that any NHS body that is the sole trustee of a charity must move that charity’s assets onto its own balance sheet.

Her position relies on a recently introduced international public accounting standard that says public sector bodies must consolidate the accounts of any organisations they control that have an income above a certain level. The DH estimates this to be about 30 of the 282 NHS charities that have NHS bodies as sole corporate trustees.

But the Commission is planning to write to the health authorities telling them they must not consolidate NHS charities’ accounts. Its official guidance says it is “wholly inappropriate” that charitable funds should ever appear on the balance sheets of public sector organisations, because it gives the impression that charitable assets are controlled by government.

Nick Brooks, head of not-for-profit at accountancy firm Kingston Smith, called the DH position “accounting dogma gone barking mad”. He said: “Consolidation should occur only if there is ownership. If you would not own the funds if the other organisation was wound up, you should not consolidate those funds into your own accounts.”

Jonathan Brinsden, a partner at specialist charity law company Bircham Dyson Bell, said he believed the commission was right to take a stand against the DH, but that corporate trustees would now be left in an invidious position.

“If I was in this situation, it would be impossible to know which authority to listen to,” he said. “Nor do I know how this conflict can be managed.”

A spokeswoman for the Commission said: “We don’t agree with the interpretation in the Department of Health’s letter. We will be following up with the Department of Health on this issue accordingly, and will also be writing to strategic health authority directors of finance to make our position clear.”

Source: ThirdSector – click here.

NHS governance related courses from ICSA

The Institute of Chartered Secretaries and Administrators (ICSA) is running three governance related one day courses for NHS participants during November 2009. Detailed are as follows. ICSA says if all three courses are booked you save 20% on total price – a saving of £237.

The NHS Trust Secretary

Price: £395 Date and location: 10 November, London CPD: 6 hours

Click here to view a detailed programme

Understanding Finance in an NHS Trust

Price: £395 Date and location: 17 November, London CPD: 6 hours

Click here to view a detailed programme

Effective Governance in an NHS Trust

Price: £395 Date and location: 24 November, London CPD: 6 hours

Click here to view a detailed programme

Note: This post is provided for information only. Unless specifically indicated to the contrary, Healthcare Governance Review does not endorse advertised training events.

The Government response to the Health Select Committee Report ‘Patient Safety’

The Department of Health has published the Government’s response to the Health Select Committee Report ‘Patient Safety.’

National Reporting and Learning System (NRLS)

The Health Select Committee stated that “After the expenditure of much effort and funding on the National Reporting and Learning System…….we are concerned that the NRLS is nevertheless still limited in its effectiveness.”

Healthcare Governance Review is particularly concerned that despite the ongoing failure of the NPSA to establish a national reporting system in line with Building a Safer NHS for patients, published in 2001, the Department of Health nevertheless contends that “The NRLS is one of the most comprehensive patient safety reporting and learning systems in the world.” We wonder how this statement can be justified given that the Health Committee states that “The [NRLS] currently amasses a good deal of summary data of doubtful usefulness [and] unlike reporting systems in other safety critical industries, and in other healthcare systems, it does not systematically gather in-depth (root-cause analysis) data on serious and sentinel events.”

Managers and Boards

Managers and boards came in for significant criticism from the Health Committee. In particular, the Committee felt that:

1. There was disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust.
2. 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.
3. Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject.
4. Patient safety is not currently, but must become the top priority of Boards.
5. No Board in the NHS should always be meeting behind closed doors.

The Government appears to have largely accepted the Committee’s finding in relation to management and boards and their responses can be found in the Government’s response document at paras. 49-57, inclusive.

Download the Government response to the Health Committee report on Patient Safety, together with the original patient safety report, here.

Lessons from a review of five London hospital fires and their management

NHS London has published  a review of five significant fires during 2008/09 at NHS sites in London, which required the evacuation of part or whole of the building. Any evacuation of a large commercial building is difficult – coping with a facility as complex as an NHS site, complete with sick and recovering patients, staff and visitors presents further challenges.

The events of 2008/09 proved that with good teamwork, leadership and planning, a safe, successful evacuation of a healthcare facility is achievable. NHS London states that it is imperative that every NHS organisation in London has tried and tested full site evacuation plans.

London’s experiences during 2008/09 demonstrate the critical importance of being prepared for emergencies. The report shares lessons learned from the five significant sires to support colleagues in the wider NHS when developing local plans.

The detailed lessons identified from the five events detailed in the report are clearly laid out in Appendix 2 to provide a checklist for planners and managers across the health service. The report will help to inform the ongoing development of the Department of Health guidance – planning for the evacuation and shelter of people in healthcare settings.

Healthcare Governance Review suggests that NHS boards assure themselves that management in their organisations are well prepared for emergencies and, in particular, have tried and tested full site evacuation plans in place.

Download the report Review of five London hospital fires and their management here.

Credit: Thanks to Peter Aldridge, fire safety manager at Leeds Teaching Hospitals NHS Trust, for bringing this report to our attention.

Governing the NHS 2010 and beyond – consultants appointed to write the new guidance

Readers may recall that the 2003 Department of Health guidance Governing the NHS: Guidance for boards is being ‘refreshed’ (see the following post).

According to Elisabeth Buggins, Chair of NHS West Midlands and the Board Development lead for the National Leadership Council “The National Leadership Council has recognised the critical role boards play in addressing the challenges of the modern NHS and I want to make sure that the whole board will benefit from up to-date guidance on governance issues.”

Working with the Appointments Commission and other partners including Monitor, the NHS Confederation and the NHS Institute, Elisabeth has established a vision that the new guidance will be ‘compelling not compulsory’.

Foresight Partnership in association with the King’s Patient Safety and Service Quality Research Centre have been appointed to develop the new guidance. According to Adrienne Fresko of Foresight Partnership “We will be looking at the extensive literature on governance to underpin the guidance but we are also keen to make sure that we are responding to the issues that Boards sometimes find difficult.”

Adrienne and her colleagues are working to a tight deadline as the new guidance will be launched at the Chairs Conference organised by the Appointments Commission on 23 February in Central London.

According to Elizabeth Buggins “We hope that the final document will assist boards in reaching the highest standards of governance, which we know is so important in achieving world class commissioning and excellent service delivery.”

Healthcare Governance Review endorses Elizabeth’s hopes and looks forward to reviewing the new guidance when it is published early in 2010.

Further information can be found in the autumn 2009 edition of Bulletin – News from the Appointments Commission, downloadable here.

Governance of health and safety – the need to ensure safe systems of operation and to carry out risk assessments

David Halcki MBE (David.Halicki@btinternet.com), independent health and safety consultant and former NHS safety professional, believes that NHS boards and managers should learn lessons from the following industrial laundry incident. In particular, he is urging boards to ensure that NHS organisations have safe systems of operation in place and carry out risk assessments both in relation to any laundry services they might have, and in relation to wider organisational health and safety matters.

The Health and Safety Executive (HSE) is urging laundry companies to ensure that they have safe systems of operation in place and carry out risk assessments after a worker was left in a coma, following an incident at a factory in Balham, Wandsworth. This follows the successful prosecution (Thursday 24 September) of a major UK laundry company at Southwark Crown Court, following an incident in October 2007. OCS Group UK Limited of Limpsfield Road, Sanderstead in Surrey was fined £80,000 and ordered to pay costs of £33,059, after pleading guilty to breaching section 2(1) of the Health and Safety at Work etc Act 1974, after Joseph Pathmananthan, a worker at the site, was injured in a serious incident.

OCS Group UK Limited provides commercial laundry services at industrial processing plants across the UK, including Balham. This plant had approximately 150 workers. 

On 2 October 2007, Mr Pathmananthan, a 61 year-old employee from Sutton in London, was working at the company’s Boundaries Road site in Balham. He was repairing the hopper unit which loads roller towels into the top of a continuous batch washer, which is an industrial washing machine costing more than one million pounds. The hopper unit needed repairing after a towel had become entangled in a lifting belt. After several different methods had been used by Mr Pathmananthan and four other colleagues to dislodge the towel, he entered the hoist’s protective cage to continue to try to remove the towel. Mr Pathmananthan was standing underneath the suspended large steel hopper. As the towel became free the hopper fell two meters onto the victim, crushing him. He suffered from multiple broken bones and internal injures and was in a coma for 19 days.  He stayed in hospital for three months and has not been able to return to work for two years since the incident.

OCS Group UK Ltd carried out an internal investigation into the incident and almost all the blame fell on a number of employees on the Balham site, including the victim who was disciplined. Despite the HSE subsequently prosecuting OCS, the company’s own internal investigation made little criticism of the company’s policies or of senior management. The HSE investigation showed that OCS Group UK Ltd did not have a sufficiently effective system for ensuring the machinery was safe to be operated and maintained, and that there were no checks on the machinery after its repair.  Also, the Balham site engineering team had not been provided with a manual which would have clearly shown how to raise the hopper safely for someone to work beneath it.  The court heard that two years prior to the incident, an HSE Inspector had attended the site and had identified that Mr Pathmananthan needed more support.

The HSE gave direction on necessary improvements including the need to risk assess the continuous batch washer, but there was no evidence this had been followed by OCS Group UK.  The HSE also found the site had inadequate controls in place to stop people slipping and tripping and that the movement of vehicles at the busy site was disorganised and dangerous.

While sentencing the company, Judge Taylor criticised OCS Group UK Ltd for what she said was a systemic failure and its complacency during monitoring. If the company had not pleaded guilty at the earliest opportunity Judge Taylor, said the fine would have been £40,000 more. Andrew Verrall-Withers, Health and Safety Inspector, said: “I was pleased the company co-operated with the investigation and made good efforts to improve after the incident, but I was surprised and disappointed that their own internal investigation failed to identify so much of what the company had got wrong.  “I hope this case sends out a message to other companies, including large ones, that it is vital they make sure that they are protecting their employees effectively. It is no good to anyone if problems are only found after it is too late.”

Healthcare Inspectorate Wales publishes 2008-09 Healthcare Standards Reports

In May 2005 the Welsh Assembly Government published Healthcare Standards for Wales, setting out a common framework to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. The standards are focused on improving the experience of patients and service users and placing them at the centre of the way in which services are planned and delivered, thus providing a basis for continuous improvement. The 32 standards include 15 concerned with ‘healthcare governance.’

This is the third year in which each of the Welsh Local Health Boards and NHS trusts, together with Health Commission Wales has been required to self assess its progress in delivering the highest level of performance against each of the 32 standards and to submit its assessments to Healthcare Inspectorate Wales (HIW) for testing and validation.

All of the Healthcare Standards reports for 2008/09, together with archived reports for the past two years, can be downloaded here.

Developing an effective, forward-looking NHS board to drive the organisation to success

One of the presentations at the Health Service Journal’s (HSJ) Leadership Forum 2009 (30 November in Central London) is titled Board level leadership: Developing an effective, forward-looking board to drive the organisation to success

Led by Elisabeth Buggins, Chair NHS West Midlands, and Mike Cooke, Chief Executive, Nottinghamshire Healthcare NHS Trust, the presentation will aim to:

1. level leaders to look out at the commercial landscape, and not up;

2. examine the role of executive coaching, and understand where it adds value; and

3. Empowering board members to understand what information they require to respond to the needs of their trust and the community

For further information on the HSJ Leadership Forum 2009, click here.

 

Mid Staffs – “It is the job of boards and board members to make choices and balance priorities”

The Health Service Journal (HSJ – 8 October 2009) has reported on the publication by Mid Staffordshire Foundation Trust of a report into the conduct and performance of its previous chief executive Martin Yeates. Mr Yates resigned in May this year after the Mid Staffs board received the report.

According to the HSJ, the report says leadership and management of the trust had improved after Mr Yeates arrived, but confirms the massive failures reported by the Healthcare Commission.

It says: “….we have not seen or heard evidence to subvert the [Healthcare Commission’s] findings that there were significant failures in the leadership and management of the trust over the period of care, and these contributed to poor clinical care.”

The report further states that “Safety and quality of care are clearly of paramount importance in any NHS trust and would therefore need to be given priority in any consideration of the conduct and performance of a chief executive. They are not, however, the only measure of performance and the trust appears to have performed well against some other targets and priorities in recent years and we make reference to some of these later in the report. But performance in one area cannot be at the expense of performance in another, especially where patient care is concerned. It is the job of boards and board members to make choices and balance priorities.”

Readers can download the report on the HSJ’s website here.

Liverpool trust fined £48k for legionella ‘complacency’

The Liverpool Heart and Chest Hospital NHS Trust was ordered to pay nearly £48,000 following an HSE investigation at the NHS Trust’s hospital on Thomas Drive, Liverpool.

The investigation found unsafe levels of legionella in the water supply system for the showers, baths and sinks at the hospital. But it was not able to conclude whether two patients, who both contracted legionnaires’ disease before their deaths in early 2007, were infected at the hospital or elsewhere.

Liverpool Magistrates’ Court heard that the NHS Trust had stopped testing the water supply for legionella, despite high levels of the bacteria being found in the Audrey Leigh wing in May 2002.

HSE criticised the NHS Trust for failing to put suitable control measures in place, and senior management for failing to take responsibility for overseeing the control of the bacteria.

The NHS Trust pleaded guilty to breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974 by putting employees and the public at risk. It was fined £35,000 and ordered to pay costs of £12,862 at Liverpool Magistrates Court on 8 October 2009.

HSE Inspector Kevin Jones said:

“It is almost beyond comprehension that Liverpool Heart and Chest Hospitals NHS Trust became so complacent about legionella in the water supply system. We were astonished to discover that the NHS Trust’s management team took a decision to stop testing for the bacteria. The hospital’s water supply system was clearly at risk from legionella and so regular tests should have been carried out.

“The NHS Trust ignored the recommendations it had been given by a specialist contractor to control the levels of legionella in the water system. No one took, or was given, responsibility for managing the bacteria, and suitable control measures were not in place.

“Hospital patients are at more risk than most of being infected with legionnaires’ disease. It’s therefore vital that NHS Trusts treat the risks seriously to help prevent deaths in the future.”

Audit Commission ‘High Performing Board’ events for existing and aspirant foundation trusts

Following the success of their high performing board seminars in 2007 and 2008, the Audit Commission is holding a series of seminars between 22 October and 26 November dedicated to foundation trusts and aspiring foundation trusts across England.

Continuing the theme of the high performing board while focusing upon quality, the seminar will support executive and non-executive directors to enhance their understanding of the right level of information required to discharge their duties.

The seminar will focus on three themes:

Quality Improvement

This presentation will enable you to learn from others by sharing the experience of delivering quality improvements in patient care and re-shaping local health services to respond to the needs of the local community.

Quality and Costs

This presentation will explore how boards ensure that they can safely reduce costs and advance quality at the same time. It will also explore successful NHS productivity and efficiency schemes.

Quality NHS leadership

This presentation will discuss and explore the benefits of creating and embedding a quality leadership culture. The seminar will allow for presentations, time for discussion and reflection. It will enable you to meet and network with colleagues working in diverse roles across the health economy.

For further information, including dates, venues, speakers and booking form, click here.

Auditors’ Local Evaluation and Use of Resources 2008/09

Each year, the Audit Commission assesses how well NHS trusts and primary care trusts manage their resources and deliver value for money. For 2008/09, these assessments have been based on the Auditors’ Local Evaluation (ALE) for NHS trusts and Use of Resources (UoR) for primary care trusts. The Commission has published a national report outlining the scores and how they should be viewed in the context of the overall financial performance of the NHS in 2008/09, which is one of a continued improvement in financial stability. NHS foundation trusts are assessed by Monitor.

Auditors make assessments in a number of themes using key lines of enquiry. There are five themes for ALE and three themes for UoR:

ALE

• financial reporting
• financial management
• financial standing
• internal control
• value for money

UoR

• managing finances
• governing the business
• managing resources

2008/09 was the first year that PCTs were assessed using the new UoR methodology. UoR differs significantly from ALE, although the process and scoring system are similar. The UoR assessment is more demanding than the ALE assessment. It is broader, with a greater focus on outcomes.

The UoR results are a building block in the new Comprehensive Area Assessment to be published in December 2009. The Care Quality Commission, Ofsted, the Audit Commission and the police, probation and prisons inspectorates are preparing a joint judgement on the quality of public services in England’s 152 local areas, geared to public opinion surveys and the needs and priorities of different places.

Key areas for improvement highlighted by the Audit Commission include:

Risk management and assurance

Although arrangements are generally adequate in this area, the ALE assessment for 2009/10 will cover what NHS trusts have done in response to the Audit Commission’s report on how boards of NHS trusts get their assurance, Taking it on Trust. The report found that although most NHS trusts have the right processes in place, the rigour with which these are applied varies considerably. In light of this, NHS trusts should review their risk management and assurance arrangements to ensure that they are robust and working effectively and that the recommendations contained in the Audit Commission report have been considered.

Demonstrating outcomes

Difficulty in demonstrating outcomes, and uncertainty over what constitutes an outcome, appears to have prevented some PCTs from scoring higher in relation to the ‘governing the business’ and ‘managing resources’ themes. Outputs demonstrate the effectiveness or impact of processes and arrangements – for example, improved sickness absence levels might be an outcome of implementing staff well-being initiatives. PCTs need to consider carefully how they can evidence outcomes and link outcomes to processes and arrangements.

The Commission also warns NHS organisations that “If high-quality services are to continue to be maintained and developed as funding growth slows down, the challenge will be to ensure that NHS trusts and PCTs plan and successfully implement efficiencies and service modernisation in advance of expected financial pressures.”

Both summary and full versions of the Audit Commission report Auditors’ Local Evaluation and Use of Resources 2008/09 can be downloaded here.

The Banking crisis: what lessons for NHS governance?

In the October 2009 issue of Healthcare Finance from the Healthcare Financial Management Association (hfma), there’s a short article by Peter Reeves, NHS non-executive director and former finance director, setting out his views on what lessons NHS governance can learn from the banking crisis.

The hfma article is based on a longer article submitted by Peter. Healthcare Governance Review is grateful to Peter for allowing us to share his longer piece with readers.

In his article, Peter succinctly compares and contrasts the differences, and similarities between governance in the banking sector with that of the NHS. He concludes that “the banking failures do indeed provide clear governance lessons for the NHS centred on the understanding of risk, the imperatives of sound information, individual board members’ responsibilities and the need for an ethos of rigour and continuous challenge, especially in areas lacking historic corporate expertise or demonstrable management capacity.  Not new lessons, perhaps, but a reinforcement of where priorities always need to lie – but too often don’t.  NHS boards, and Finance Directors individually, should not miss the opportunity to reassess their own situations accordingly and in light of increasing funding pressures.”

Read Peter’s full article here – Article_for_Healthcare_Finance

U.S. health board rubber-stamps CEO ‘corruption’

Board members at MetroHealth Medical Center in Cleveland, Ohio, USA, are wondering how they missed several warning signs that something was wrong with the conduct of former executive John Carroll.

Carroll pleaded guilty earlier this month to taking more than $600,000 in bribes over nearly 10 years in exchange for inflated construction contracts that the board approved.

According to Rick Wade, a spokesman for the American Hospital Association’s Center for Healthcare Governance, communities in the USA have raised their expectations of hospital boards and expect them to demand the necessary information from management so the trustees can properly oversee operations. “Overseeing and managing a hospital has become ever more complex,” Wade said. “You are in command of a huge amount of community resources that have to be spent wisely.”

As reported on www.cleveland.com a few of the trustees of the board of MetroHealth Medical Center are grappling with how they missed the signs. “You depend on one another. What you don’t know, you hope that somebody else can figure out,” said Polly Clemo, who has been on the board since 1995. “I don’t know that we knew what to ask,” she added.

For further information on this story, click here.

‘Healthcare boards should learn from banking leaders’

According to US physician, Charles R Denham MD, “Board members should learn from banking leaders who ignored risk and their responsibilities out of selfishness. Moral relativism and situational ethics are not going to cut it in the new world of transparency. The bankers’ governance issues are no different from ours in health care – this is about leadership, accountability, and values.”

In a paper published in the Journal of Patient Safety (Volume 5, Number 2, June 2009) Dr Denham asks “Is Your Hospital as Safe as Your Bank – Time to Ask Your Board.”

He suggests that “When we compare our financial collapse to our patient safety crisis, there are striking similarities.”

Dr Denham’s paper makes for interesting and though provoking reading, especially for boards members.

The paper can be freely downloaded here.

The paper

Mutual governance in action at South Staffordshire NHS foundation trust

Readers may be interested in the South Staffordshire Healthcare NHS foundation trust’s ‘mutual governance’ approach to governance.

The trust has been implementing mutual governance since 2005 and has produced a handbook on mutual governance, which can be downloaded here.

Thinking about risk – HM Treasury guidance

HM Treasure has published three documents concerned with risk for boards and risk management practitioners. This is not new guidance, so some readers may already have seen it.

According to HM Treasury, it is essential that the board’s attitude to risk is communicated to the whole organisation and applied in decision making regarding the prioritisation of policies and the funding that goes with them.

The HM Treasury guidance provides an overview of the concept of ‘risk appetite’ and aims to help boardss refine their application of their organisation’s risk appetite so that risk judgements are more explicit, transparent and consistent, in the hope that it will enable boards to have the best opportunity of achieving their corporate goals.

The three documents are:

- Thinking about risk, Managing your risk appetite: A practitioners guide

- Thinking about your risk: Setting and communicating your risk appetite

- Thinking about risk – Managing your risk appetite: Good practice examples

The guidance can be freely downloaded here.

World Class Commissioning Assurance Handbook – Year 2

The Department of Health has published its assurance handbook for year 2 of World Class Commissioning.

It is disappointing to note from the handbook contents that the Department of Health continues to fail to understand governance and the role and function of boards as governing bodies.

The handbook states that “The principle [sic]  functions of the PCT board are to set the strategic direction for the PCT and to exercise effective oversight and management. At all times the board members are accountable to the NHS and their local population for how they oversee investment and prioritisation and manage clinical, operational and service performance to drive better health outcomes, improve quality and reduce inequalities. The overriding objective of the board assessment is to understand the board and its sub-committees’ grip on the organisation, and their ownership and control of the commissioning agenda.”

In summary, the Department sees PCT boards as management boards – not governing boards, although they do talk of boards ‘oversight’ role.

Download the Year 2 World Class Commissioning handbook here.