Select Committee on Health Written Evidence

Memorandum by Monitor (PS 65)



  Monitor, the Independent Regulator of NHS Foundation Trusts, is responsible for ensuring that NHS foundation trusts are effectively governed and meet the requirements of their Terms of Authorisation. While we do not define standards for safety and quality, NHS foundation trusts are required to comply with the Department of Health's national core standards and targets. Monitor treats failure to meet these targets as a potential governance issue and in cases of significant breach of an NHS foundation trusts terms of authorisation, including in relation to safety and clinical performance we have effective powers of intervention.

  Boards of NHS foundation trusts should understand the quality of the services they offer and lead improvement. Monitor is keen to support Boards of NHS foundation trusts as they develop their capacity to do this at Board and Service Line level. The development of credible and widely accepted measures of safety and quality will support the efforts of both provider Boards and commissioners to improve quality and help ensure regulators can intervene effective if required.

  1.  It is not Monitor's role to define standards of quality and safety. Monitor's role is to ensure NHS foundation trusts are effectively governed and to tackle failure both clinical and non clinical where it occurs.

  2.  In many cases safety issues are a product of weak governance. Monitor's role is to fix these weaknesses in governance and ensure NHS foundation trusts are professionally managed.

  3.  Our approach to ensuring good governance is based on:

    i.  reinforcing the responsibility of the Board of the NHS foundation trust for all aspects of their trust's performance. We approach failures in service or financial performance as failures in governance. If we have to intervene it will be to correct the underlying governance failures.

    ii.  setting clear obligations on NHS foundation trusts in their terms of authorisation and in Monitor's Compliance Framework. In relation to safety and quality the Trust and Monitor's compliance framework place a number of requirements on NHS Foundation trusts

    —  Boards are required to self certify that their NHS foundation trust has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to their patients. Boards are expected to be able to describe their own objectives for improving quality and to identify metrics to monitor quality in terms of clinical outcomes, patient safety and patient experience along with expected levels of performance

    —  NHS foundation trust are required to meet the DH national targets including those relating to HCAI, an important patient safety concern

    iii.  requiring NHS foundation trust Boards to self certify that they meet the requirements set out in the Terms of Authorisation and the Compliance Framework. This approach again emphasises the importance of the Board satisfying itself that its NHS Foundation Trust meets the requirements placed on it

    iv.  transparent reporting, the NHS Foundation Trusts Reporting Manual will require NHS foundation trusts to report their own quality objectives, metrics and expected performance in their Annual Accounts for 2008/09

    v.  monitoring compliance and intervening where necessary. Monitor's Compliance Framework sets out the full details of our approach but in essence we use performance against the national core standards and targets as an indicator of good governance. We also place significant weight on reports of third parties such as the Healthcare Commission and would seek to work with such expert bodies in tackling any safety or quality failure. Where we judge a NHS foundation trust to be in significant breach of its Terms of Authorisation we have wide ranging powers of intervention including powers to instruct the FT or to remove the Board.

  4.  The most prominent patient safety and quality issues we have dealt with to date relate to the performance of some NHS foundation trusts against their target for reducing the number of MRSA infections and using Standardised Hospital Mortality Rates (SHMR) to inform our assessments of trusts applying for NHS foundation trust status.

  5.  In the case of MRSA performance Monitor has escalated regulatory action for 8 NHS foundation trusts based on the MRSA performance in 2007/8. Five of these trusts were found to be in significant breach of their Terms of Authorisation. Monitor wrote to each trust confirming they would be red rated for governance and to the extent they failed to meet their MRSA target each quarter in 2008/9, the actions we may consider taking. None of these trusts subsequently exceeded their trajectory at Q1 2008/9.

  6.  The quality of care provided by the trust also forms part of our assessment process for trusts applying for foundation trust status. During an assessment we use Standardised Mortality Rates to introduce discussion of the trust's understanding of, and approach to the quality of its services. We have also developed close links with the Healthcare Commission and seek their views to inform our assessment.

  7.  It is our belief that sustained improvements in safety and quality will only occur if the Boards of NHS organisations take responsibility for and lead improvements in safety and quality. There is good evidence that engaging Boards in the quality agenda works. Research in the USA shows better outcomes are associated with hospitals in which the board spends more than 25% of its time on quality, clinical staff are engaged in the quality strategy and the CEO is identified as having the greatest impact on quality

  8.  Monitor is therefore keen to support NHS foundation trusts as they seek to improve their own practice.

  9.  To date we have focused on the introduction of Service Line Management. Helping NHS foundation trusts to organise themselves so that the clinical leaders of each service have the information to understand their performance in both clinical and financial terms and the authority to manage their services to deliver improvements. While we started this work with financial reporting our ambition is to see NHS foundation trusts able to report financial and clinical performance alongside patient and staff experience at a service line level and use this information to drive service improvement.

  10.  We are planning further initiatives to support NHS foundation trusts in managing the quality of their services at both Board and Service Line levels. We have proposed a Service Line Academy to provide Clinical Directors with the management training they need to operate effectively as service line managers. In developing the curriculum for the Academy we would be able to draw on both our experience in implementing Service Line Management and the experience gained from establishing the successful Finance Director training programme with CASS Business School.

  11.  There are already good examples of NHS foundation trusts' Boards taking forward the quality agenda and Monitor is currently exploring the possibility of working with a small group of NHS foundation trusts' boards to pilot and develop best practice in the Board's role in leading the quality agenda within NHS foundation trusts. We would expect the work to enable us to produce best practice material to be made available to all NHS foundation trusts.

  12.  We believe that transparent reporting of safety and quality is a crucial element in ensuring these issues are central to the agenda of healthcare organisations. We are therefore supportive of the concept of Quality Accounts as announced by Lord Darzi in High Quality for All and we are exploring ways to work with NHS foundation trusts and the CQC to produce pilot Quality Accounts from next summer. The introduction of a true and fair account of the safety and quality of an NHS foundation trust's services could be a powerful driver both in focusing Board and staff attention on improving quality and in influencing patient and public understanding of the NHS.

  13.  Credible, clinically appropriate metrics are crucial to improving safety and quality. They will allow clinicians, Boards and commissioners to understand the quality of care and drive improvements. Effective metrics will also allow regulators to identify when and where we may need to intervene. To date there has been no real consensus on the right approach, an authoritative source of advice on the measurement of safety and quality is required to address this. Monitor welcomes the emphasis placed on measuring quality by Lord Darzi and looks forward to working with the Department of Health and the Care Quality Commission to ensure that our approach to monitoring good governance in NHS foundation trusts takes account of emerging good practice in measuring and assessing safety and quality.

  14.  Monitor welcomes the greater attention on patient safety and quality. We do need a better consensus on how to measure and report safety and quality. As this develops we will consider how Monitor can evolve its Compliance Framework so that our assessments of the governance of NHS foundation trusts place sufficient weight on the safety and quality of care delivered by the NHS foundation trust.

September 2008

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Prepared 30 October 2008