Robert Francis QC’s report into the Mid Staffordshire Inquiry is due to be issued to the Secretary of State in January 2013. The terms of reference require the Inquiry to identify how “failing and potentially failing hospitals or their services” are identified as early as possible. However, it seems clear that the lessons in terms of internal governance and interaction with, and between, commissioning, regulatory and oversight bodies are ones which are likely to provide valuable learning beyond the NHS and across the entire health and social care sector.
Whilst the Inquiry’s detailed findings and recommendations are awaited, an examination of the evidence identifies a range of themes to which the sector should have regard in anticipation of the final report and beyond. In this alert, we focus on the theme of the effectiveness of provider boards.
The board of any company or NHS organisation should be an effective board which is collectively responsible for the long term success of the organisation and the directors should be acting on what they consider to be the best interests of the organisation consistent with their and its statutory duties. These principles are enunciated in the combined order of corporate governance, and reflected in Monitor's good practice guidance.
In the context of healthcare providers whether public or private the provision of safe high quality care lies at the heart of care provision. Indeed in the context of NHS board members, the recent standards issued by the Professional Standards Authority includes a requirement of “Always putting the safety of patients and service users, the quality of care and patient experience first, and enabling colleagues to do the same”. Further, Monitor proposes “that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations” as a governance condition of the new licences for foundation trusts.
How then do boards properly assure themselves that the quality of the services they are providing is good enough? With the background to the Mid Staffordshire Inquiry in mind, how do they ensure that there is adequate consideration given to quality of service issues when there are other major matters effecting the strategic direction of the organisation such as foundation trust applications, PFI schemes or indeed the organisation's overall financial position? It has been suggested that the excess focus on the FT application may have been a contributory factor on the failings in Mid Staffordshire, and the PFI similarly in the Maidstone C. difficile outbreak.
There are some basic building blocks for any healthcare organisation to use for issues around quality of care. These will include having the proper systems in place for the delivery of healthcare and particularly over the handovers of patients between healthcare professionals whether inside the organisation, at the beginning and end of shifts, or at the point of transfers in or out so as to ensure that the necessary information that needs to go with patients actually travels and is received and understood by the recipient. Part of this will flow from having adequate properly trained staff and the appropriate level of protocols and procedures in place. It will also depend on the organisation having cultivated the necessary internal culture so that all members of staff recognise and have a focus on the quality of care being provided.
The board can significantly influence this in several ways. Firstly there is the structural and organisation element to this. The board needs to ensure that the pinnacle quality of service is consistently reviewed across all service lines that are provided, and that there is robust data on outcomes and other quality markers including patient experience which are collected reviewed and reported up to the board where appropriate. For example, in the case of Mid Staffordshire, the Inquiry received evidence that the paucity of information reaching the board about the large numbers of adverse incident reports citing understaffing was an important factor in allowing changes in workforce to be made without a real appreciation of their likely impact.
Providers need to have good data and a proper structure for ensuring that the focus is not purely on a limited number of high profile services. Data should also be benchmarked so that the performance of the organisation relative to others can be checked. Whilst being better than mediocre competitors is not necessarily enough, not being as good as others should require investigation and questioning to see how the organisation can improve. Quality and risk committees (or their equivalent) should have a coherent plan for the rotation of reports so that adequate time can be given to an individual service on a regular basis. The key here is to have a system in place that ensures so far as possible that processes and procedures that exist on paper also exist on the ground in the way in which patients are treated; and that this is kept under review so as to ensure that the policies do not become outdated. For the NHS, much of this is reflected in the quality governance memorandum required as part of the DH phase of FT applications.
Perhaps more widely and yet more fundamentally, the board by its actions and approach can help to inform the culture of the organisation and ensure that this is one where the focus is on delivery of care to patients. This can be approached by a range of different tools but we would certainly recommend boards to ensure that they have visibility amongst front line staff and patients so that they see and are seen to be seeing what is going on on the ground and can hear first-hand the experiences of individual patients and members of staff. Whilst this evidence may be anecdotal, it can provide a useful cross check against the more anonymous data that may be received through the more formal reporting mechanisms and can be used to validate or challenge those reports.
Similarly, the way in which an organisation is seen to focus its time at board level and the sense of what the board value as important either, in terms of what they reward or what they are intolerant of, will have an impact on the culture within the organisation. This can be achieved through relatively indirect routes or the more direct celebration of success and things such as appraisal mechanisms. The greater the impression that the board is serious about quality, the greater the impact that will have about the way in which staff carry things out, and conversely if the board is seen merely to pay lip service, it will have little impact in terms of the culture within its services.
Another key issue will be the support given by the board to whistleblowing. The board needs to take events of whistleblowing seriously, although again, particularly in times of change, it is important not to allow this to undermine the need to manage the organisation. The board may want to support the management but it is important to properly consider concerns and where appropriate get an external view.
All of this is not to say that a clear sense of the financial performance of the organisation is irrelevant; without robust finances continued quality cannot be delivered. Perhaps another way of putting this would be to ask if you cannot deliver a safe, good service for the money available should you be doing it at all?
Quality of service needs to be at the heart of healthcare – and at the heart of the Board Agenda.
It remains to be seen whether Robert Francis’ report will underpin the requirements of good governance with a recommendation for increased accountability for board members and senior managers. Any such move would appear to be consistent with the trend for the adult social care sector indicated by the government in recent final report into the review of events at Winterbourne View in which it has highlighted proposals to strengthen the accountability of directors and managers for the safety and quality of care which their organisations provide.
Conclusion and next steps
It is likely that the Inquiry will make a number of recommendations to address issues of organisational culture and enhance systems of corporate governance. Bevan Brittan’s team has a wealth of experience in advising healthcare organisations.
Once the report is issued all colleagues will need to reflect on what its findings and recommendations mean for them. To help consideration of this, Bevan Brittan is hosting a series of seminars in February and March 2013 to consider the implications following its anticipated publication. The scheduled dates for these seminars are as follows:
Bristol: 20 February 2013
If you would like to register interest in attending any of these events please click on the above dates and locations to view further details and respond.