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.

NHS Governance 2009 conference a success

The Health Service Journal’s (HSJ) annual NHS governance conference held over 3-days at Earls Court in London this week attracted over 300 delegates across the different days, with some attending two or all three days.

The conference was a great success with a host of excellent speakers plus good audience participation during panel sessions, etc.

The general state of chaos and confusion around governance and management was a key issue to come out of the event. The speaker from the new Care Quality Commission added to the confusion by saying that “governance relates to consistent management, cohesive policies, processes and decision rights for a given area of responsibility.” This is a new definition that does not align with the myriad definitions already in place in various NHS guidance documents, and does not conform to key thinking about governance. Interestingly, another speaker coined a ‘new’ governance term at the event. Professor Paul Stanton spoke about “intelligent governance.” Healthcare Governance Review looks forward to the day that the subject of governance in the NHS will be addressed ‘intelligently’ by the Department of Health and associated agencies and bodies, including the new Care Quality Commission!

The presentations from the event should be posted on the web for free download by 3 July. When available, download the presentations by clicking here.

Thome report on Mid Staffordshire looks to ensure governance and clarity of accountability

Dr David Colin Thome, National Director for Primary Care at Department of Health, has published his report on Mid Staffordshire NHS foundation trust alongside Professor Sir George Alberti’s report (click here).

Dr Thome makes recommendations in four key areas:

1. Involving patients and the public
2. Commissioning for outcomes supported by excellent use of appropriate data and information
3. Ensuring governance and clarity of accountability of all the different organisations in the system
4. Clinical leadership

It is refreshing to note that Dr Thome does not fall into the usual trap of confusing governance with management. There is no mention of boards managing the organisation and there is no reference to ‘Governance between organisations.’

His recommendation relating to ‘ensuring governance and clarity of accountability of all the different organisations in the system’ appear balanced and cover:

1. PCTs as local leaders of the NHS must assume ultimate responsibility for commissioning safe services and improving the health of their patients and populations.
2. All hospital providers including foundation trusts must allow PCTs ready access to review their services.
3. SHAs are the regional headquarters of the NHS, and in that role must ensure that the whole healthcare system discharges its responsibilities, with a particular emphasis on the performance management of PCTs to ensure that they are taking forward their leadership role. The Commissioning Assurance System for world class commissioning provides a framework for taking this forward.
4. PCTs and SHAs must be more proactive in informing Monitor of any concerns prior to foundation trust application and not assume that the regulators will take responsibility for ensuring quality of care. The regulators must share data and early concerns to allow PCTs and SHAs to take action.
5. The Department of Health should describe how the roles of PCTs, SHAs and the regulators are different and how they interrelate.
6. The Department of Health should set out clear expectations on all health organisations that effective ‘business continuity planning’ is the norm, and work in co-production with the NHS to develop guidance for organisational transition, including effective formal record keeping.
7. The NHS Confederation should consider how it can support PCTs through its network to develop their capacity and capability to respond to their role as local leaders of the NHS following lessons to be learnt from this review.

The Department of Health has published its response to the Alberti and Thome reports and this report, together with copies of the Alberti and Thome reports can be downloaded here.

Forthcoming book – Governing the New NHS

The authors of the Integrated Governance and Governance between Organisations publications, Michael Deighan, John Bullivant and Andrew Corbett-Nolan, are involved in a new book due for publication on 28 February 2010 by Routledge.

Currently titled Governing the New NHS – Issues and Tensions in Health Service Management (sic) the book will build on the authors’ collective experience of their approach to governance that they have been promulgating across the UK NHS.

According to the publisher’s information on the book, “Governing the New NHS makes sense of the new systems and will enable anyone interested in healthcare governance to navigate their way confidently through the confusion. It describes, assesses and critiques the new governance arrangements. It examines how they are working in practice, reporting on how practitioners are making sense of, and responding to, the difficulties and paradoxes that arise. The book:

- Explains current governance arrangements and explores related issues and tensions – such as those between the devolved countries, and primary and secondary care trusts.
- Discusses the roles and interrelationships of boards and effective board practice.
- Debates the nature of effective governance and how to do it well
- Looks at how to ensure seamless governance and service provision in a fragmented NHS – avoiding gaps and problems between different health service providers.”

Whilst Healthcare Governance Review has previously been critical of the authors’ apparent understanding of the distinction betweeen governance and management (e.g. click here and note also the proposed title and strapline for the book, above!), nevertheless this book will undoubtedley be an essential purchase for anyone with an interest in healthcare governance.

For further information, click 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.

Whose NHS is it anyway? Have your say……..

The NHS Alliance is looking for diverse views around the UK from patients, carers, NHS board members, GPs, nurses and other health professionals and of course members of the public whose taxes pay for our most important public service. The debate will continue with regional meetings and the Alliance will bring your ideas together at the end of the debate.

To stimulate your thinking have a look at the discussion paper “Whose NHS Is it anyway?” which can be downloaded below. What do you think about its six questions on NHS accountability and the practical suggestions for patient and public involvement in the NHS “with teeth”.

The new NHS Constitution says “The NHS belongs to the people”. Help us find out what that really means by saying what you think it means to be one of the owners of the NHS.

The floor is all yours…..please leave your comments below. You don’t have to say who you are, but it would be helpful to know what you do or represent (e.g. patient, carer, GP, nurse, NHS board member, member of thee public, etc.).

Download Whose NHS is it anyway?

Participate in ISQua 2009 quality conference, October, Dublin – Governance & Leadership track

Are you and/or your organisation interested in speaking or presenting a poster at one of the world’s biggest annual healthcare quality conferences 11-14 October this year in Dublin?

The 2009 annual conference of the International Society for Quality in Healthcare (ISQua) is focusing on the highly topical issue of designing quality into healthcare organisations. This is a major annual event attracting up to 1000 delegates and speakers from all over the world.

One of the tracks for the conference is ‘Governance and Leadership’ and Stuart Emslie, editor of Healthcare Governance Review, is assisting ISQua with this aspect. The key question being addressed by this track is “How is the quality and safety function best designed into the organisation construct of our Health Systems at National, Regional and Local levels?”

Possible areas of focus include:

· Where does the quality (including safety and risk management) function fit into Health Organisations at Corporate level and what is its role?
· How does the delivery system organise for quality?
· How does the Corporate quality function relate to the delivery system i.e. National, Regional and Local level inter-relationships
· How do we design the system such that roles, authority, responsibility and accountability for quality is clear and unambiguous?
· Within this framework, how are standards and quality, as well as safety and risk management, assured?

For further information or to submit an abstract (deadline 20 March 2009) click here or, alternatively, contact Stuart Emslie directly on svemslie@aol.co.uk or by telephone on +44(0)7932376562.

NHS Governance 2009 – A three day event organised by the Health Service Journal

The Health Service Journal (HSJ) is presenting its 5th annual governance conference as a three day event in London on 23-25 June 2009.

Day 1 (23 June) will look at ‘Transformational NHS Governance – Developing robust, flexible and fit-for-purpose governance systems to support whole system change.’

Day 2 (24 June) will look at ‘Board Level Development – Cultivating the skills to strengthen governance systems from board to ward and beyond.’

Day 3 will look at ‘PCT Governance – Developing sound governance for commissioning arms, provider services and the body corporate.’

Full details about the event will appear in due course and can be found here.

In the meantime, please ensure the event is in your diary.

Government publishes NHS constitution for England and statement of NHS accountability

The NHS Constitution was published on 21 January 2009. It was one of a number of recommendations in Lord Darzi’s report ‘High Quality Care for All’ which was published on the 60th anniversary of the NHS and set out a ten-year plan to provide the highest quality of care and service for patients in England.

The Constitution commits the Government to providing a statement of NHS accountability. This document accompanies the NHS Constitution and provides a summary of the structure and functions of the NHS.

Both the NHS Constitution and the statement of NHS accountability are key documents relating to the governance of the NHS in England.

According to the government, “The NHS belongs to us all. The NHS Constitution brings together in one place for the first time in the history of the NHS, what staff, patients and public can expect from the NHS.

As well as capturing the purpose, principles and values of the NHS, the Constitution brings together a number of rights, pledges and responsibilities for staff and patients alike. These rights and responsibilities are the result of extensive discussions and consultations with staff, patients and public and it reflects what matters to them.

Subject to Parliamentary approval, all NHS bodies, and private and third-sector providers supplying NHS services in England will be required by law to take account of the Constitution in their decisions and actions. The Government will have a legal duty to renew the Constitution every 10 years. No Government will be able to change the Constitution, without the full involvement of staff, patients and the public.”

Download the NHS constitution and statement of NHS accountability, along with other documentation, here.

‘What gets measured gets done’ says Sir Ian Kennedy as Healthcare Commission prepares to bow out…..

The Healthcare Commission (HCC) will be replaced by the new Care Quality Commission (CQC) from 1 April 2009.

In the final State of Healthcare report for 2008, Professor Sir Ian Kennedy, Chair of the HCC, believes that the Commission has painted a ‘richer picture’ of NHS performance than has existed in this past. This, he says, “has led boards of trusts to concentrate ever more intensively on what matters.” Indeed, his parting words of wisdom for the NHS appears to be the old maxim “what gets measured gets done.”

According to the HCC, the NHS must now focus on enhancing the quality of care by doing more to measure outcomes for patients, the experience of patients, and the journey people make through the system of care.

Sir Ian Kennedy said: “It is crystal clear that there have been major improvements in the care provided by the NHS over the past five years.

“We have seen more money going in, more staff providing services and more patients being treated. People are getting care much more quickly than they used to, notably for cancer. NHS trusts have, for the first time, a clear understanding of the core standards of service that they should be providing. We are seeing signs of real progress in driving down rates of healthcare-associated infection. People are living longer and there have been some remarkable reductions in premature deaths from the major killer diseases.

“But there are a small number of trusts trapped at a level of performance that is unacceptably poor. It’s also clear that, while patients overall indicate high levels of satisfaction with care, the NHS is still playing catch up when it comes to consistently providing the patient-centred care that people rightly demand. This is particularly true for those least able to make themselves heard when it comes to getting the best care, such as older people, children and those with mental health needs or learning disabilities. There have been some real improvements in mental healthcare but significantly more remains to be done to support people, especially young people, in the community.”

He added: “We have made the safety of care our highest priority. Safe care is the first building block of good quality care. It’s clear that safety is higher on the agenda than ever, but we are also a long way from an NHS that hungrily and systematically examines its own performance, gathers in and learns from mistakes, reinforces good practice, and does things differently for the future.

“The Healthcare Commission is four years into what was planned as a long-term project. The improvements so far are clear but the pace of change has varied. It is very important that the momentum be maintained.”

Key points from the report include:

- The NHS has benefited from major increases in funding and now has more resources than at any time in its history
- Demand for care has also risen dramatically
- The health of the nation is improving
- There have been sustained improvements in meeting the government’s standards and targets, with dramatic    improvement in waiting times
- There is a small number of trusts trapped at a level of performance that is unacceptably poor
- Services are still not always as patient-centred as they should be and there are groups of patients whose needs are still not sufficiently well served
- The safety of care is higher up the NHS agenda but trusts are still not doing enough to monitor and learn from incidents and ensure good practice is followed
- Commissioning must improve, as must measurement of patient outcomes, the experience of patients, and the journey people make through the system of care.

In relation to the safety of care, Sir Ian said Sir Ian said the issue of patient safety had risen up the Government’s and the NHS’s agendas. “But in my view the NHS is really only just out of the starting blocks,” he said. “There’s a great deal to do before we can be confident that the care patients receive is as safe as it reasonably can be.

“We are a long way from an NHS which systematically and hungrily examines its performance, reinforces safe practice, gets in and learns from things that go wrong and does things differently and more safely as a consequence.”

Download the HCC’s State of Healthcare 2008 report here.

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.

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.

No Authority? Then No Accountability – the ‘Policy Governance’ view of the NHS Constitution

The consultation on the proposed NHS Constitution closed last week.  According to the MAC Partnership in London, “the UK Policy Governance Association (UKPGA) said it all……”

The UKPGA submission focused on two key aspects: accountability and local determination of needs. Those have to sorted out first before service users can be clear about what their entitlements to services are. But the NHS Constitution lacks a statement of accountability – ie there is no answer to the question “to whom is it accountable and for what and how is that accountability to be exercised?”

Read the MAC Partnership’s view on all of this here.

DH consults on failure regime for NHS organisations

The Department of Health’s (DH) publication Developing the NHS performance regime, published 4 June 2008, announced the Government’s intention to “establish a failure regime for state-owned providers that reflects the Government’s obligations to ensure service continuity and protect public assets.”

The DH is now consulting on their proposals for such a regime and seeks views on them by 3 December 2008.

Meanwhile, according to a Health Service Journal (HSJ) report (18 September 2008), up to 92 trusts could be “culled” as part of the “NHS failure regime.” For further information, read the HSJ article here.

Download the consultation document Consultation on a regime for unsustainable NHS providers here.

UPDATE 19 September 2008 – Read Paul Dutton’s article (19 September 2008) on failing NHS foundation trusts in the Health Service Journal here.

Building a culture of patient safety through effective governance in Ireland

The report by the Commission on Patient Safety and Quality Assurance in Ireland is now published. Titled ‘Building a culture of patient safety’ the report sets out a governance framework for patient safety and quality in Irish public healthcare.

At 242 pages long, this is a comprehensive and extensive report (and it contains 219 mentions of the word ‘governance’ – Ed.).

The vision around which a health system-wide governance framework for patient safety should be based is stated in the report as “Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes.”

Healthcare Governance Review spoke to Dr Deirdre Madden, Chairperson of the Commission on Patient Safety and Quality Assurance, about the report. In particular we asked her about the report’s focus on effective governance as a means by which a culture of patient safety and quality can be effected.

Dr Madden said that “Medicine is not a risk-free enterprise; errors occur in every healthcare system in the world. However, we must never be complacent about errors, and must recognise and face the serious consequences that errors have for patients, their families and the clinicians involved. We must develop a positive patient safety culture by putting in place structures and systems that ensure effective governance in our healthcare facilities based on strong and clear reporting relationships and delegated levels of authority, robust accountability mechanisms and patient involvement at all levels of healthcare decision making. We must ensure that the potential for error is minimised to the greatest extent possible by strong professional leadership on safety and quality, active participation in audit, and commitment to sharing lessons learned from adverse events. A system-wide approach to safety and quality will help to ensure that wherever a patient receives care, it will be safe and effective, delivered by appropriately skilled professionals in facilities that are well governed, fit-for-purpose and have patient safety as their paramount priority in all that they do.”

Readers are strongly encouraged to read the report, which, in the opinion of Healthcare Governance Review, paints the most complete and comprehensible understanding of healthcare governance that presently exists anywhere in the world.

Download a copy of the report here.

Related link.

Local accountability of health services – Discussion paper

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

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

To read the paper click here.

Simon Jones on NHS Governance

Writing in the Health Service Journal, Simon Jones, Chair of the NHS Confederation Wales and of Cardiff and Vale Trust, provides some interesting views on NHS governance, and appears to favour the NHS foundation trust governance model as an approach that Wales can learn from.

Read his article here.

Irish report on ’system of governance’ for quality and patient safety imminent

According to the Irish Medical Times (18 June 2008) the Department of Health in Ireland has announced that the Commission on Patient Safety and Quality Assurance will publish its report on the licensing of public and private healthcare providers and services in July 2008.  Currently, there is no system of regulation for private healthcare providers.

The Commission will develop proposals for a system of governance based on corporate accountability for the quality and safety of health services, the Department stated. They will apply to both public and private providers, essentially creating one standard. The Commission will also devise:

* a system of leadership for clinicians and managers which would underpin robust corporate accountability for institutional and clinical performance;
* a statutory system of licensing for public and private healthcare providers and services;
* the process of quality assurance of clinical services (with an emphasis on clinical outcomes) for public and private healthcare providers and services;
* procedures for healthcare professionals and managers to anticipate risks and promote good performance through effective risk identification, near-miss and critical incident reporting;
* the governance of regulatory bodies in the health system and ways in which effective integration can be enabled between the various bodies.

‘Commissioning Assurance’ – Department of Health reinvents ‘controls assurance’ for PCTs

The Department of Health has published its Commissioning Assurance Handbook as part of its World Class commissioning initiative. World class commissioning is about delivering better health and wellbeing for the population, improving health outcomes and reducing health inequalities. In partnership with local government, practice based commissioners and others, Primary Care Trusts (PCTs),supported by Strategic Health Authorities (SHAs), will lead the NHS in turning the world class commissioning vision into a reality, adding life to years and years to life.

The approach being adopted for Commissioning Assurance is highly reminiscent of the Department of Health’s former Controls Assurance process for the NHS. Commissioning assurance will hold Primary Care Trusts (PCTs) to account and will reward performance and development as they move towards so-called ‘world class’. The definition of ‘world class’ will, apparently, continuously evolve, and commissioning assurance will develop in response.

There are three elements of commissioning assurance: outcomes, competencies and governance. Outcomes reflect the overall improvement in the health and well-being of the population. Competencies reflect improvements in the PCT’s skills and behaviours as commissioners. Governance reflects the underlying grip that the Board and the organisation have on their core business. In addition the assessment will review the PCT’s potential for improvement.

The DH says there will be one nationally consistent commissioning assurance system managed by the Strategic Health Authorities (SHAs). As set out in the Operating Framework 2008/09, commissioning assurance applies to all SHAs and PCTs. Within the established annual cycle it will be a consistent assurance system to review PCT progress towards world class performance and achievement of better health outcomes and provide a common basis for agreeing further development. Nationally consistent methodology will, according to the DH, enable reliable comparison of performance across all PCTs.

TheCommissioning Assurance Handbook contains further information and can be downloaded here.

How come we know so little about the outcomes of care in an industry that annually spends £100 billion of taxpayer’s money?

In a thought provoking opinion column article in the Health Service Journal (HSJ), Dr Andrew Jones, group medical director of Nuffield Hospitals and health policy advisor to Andrew Lansley, conservative party shadow health spokesman, says the solution for providers feeling the squeeze has to be quality, and the measures to align the system have to be outcomes.

He contends that open publication of provider performance [based on outcomes] “would put the pride back into services, push clinicians and managers to innovate and give patients a real choice as institutions compete.”

His ”three wishes” for improving the quality of healthcare are:

1. to universally collate independent user satisfaction scores to assess the responsiveness, accessibility and quality of healthcare delivered;

2. to create a quality and outcome performance system for secondary care to measure the outputs of that care, such as readmission or 30-day survival; and

3. to roll out a system of patient-reported outcome measures for all elective procedures and many chronic conditions.

Read the full text of Dr Jones’ HSJ opinion column on health outcomes here.