10 The role of managers and Boards
269. The day-to-day running of NHS organisations
rests in the hands of managers and Boards. These include both
executive and non-executive directors, the latter being tasked
with holding the former to account. In this chapter we consider
how well they are discharging their responsibilities in respect
of patient safety.
270. The first point in the Code of Conduct for
NHS Managers (2002) reads "As an NHS manager, I will
[
] make the care and safety of patients my first concern
and act to protect them from risk". Governing the NHS:
A guide for NHS Boards (2003) states:
The duty of an NHS Board is to add value to the
organisation, enabling it to deliver healthcare and health improvement
within the law and without causing harm [
] It is the duty
of the Board to ensure through Clinical Governance that the quality
and safety of patient care is not pushed from the agenda by immediate
operational issues.[268]
271. Two regulatory bodies, Monitor and the HCC,
were keen to emphasise that ultimate responsibility for standards
of care in each NHS organisation rests with squarely its Board:
Q 693 [
] Dr Moyes: [
] The
other thing I think is quite important is the emphasis that we
have placed on the role of the board, because the other thing
that I think has been lacking in the past has been absolute clarity
about who is accountable for the delivery of services in the round,
and we are quite clear in foundation trusts that that is the board.
It is not the medical director, it is the board. Therefore, saying
to the board, "You are accountable and you have to give an
account of yourself and, therefore, you have to know what is going
on in your hospital and you have to have ways of spotting the
areas of problem and intervening", I think also would be
very powerful [
]
Q 697 [
] Professor Sir Ian Kennedy:
[
] [T]he emphasis on the board that Bill [Moyles] laid earlier
is critical, it is a view we share, but [
] if I were the
Chairman of a board I would not be entirely sure who I am obliged
to please, as it were, and that requirement for clarity will now
depend upon the working together of these two agencies [Monitor
and the CQC]. The structures, because they have grown, they have
grown a bit like Topsy, and they do need very powerful and insightful
leadership, otherwise, as I say, if I was the Chairman of a local
trust I would not know quite what the tune is we are playing,
or I might not.
272. Several recent HCC investigations have shown
in detail how senior managers and Boards have failed in their
most basic duties as regards patient safety, with disastrous consequences.
In each of these cases, patient safety was found to have been
crowded out by other priorities, including the meeting of targets,
financial issues, service reconfigurations and achieving Foundation
status. As we have already noted, in these cases inadequate staffing
levels have been a particular factor in compromising patient safetydespite
the enormous increase in funding and staffing across the NHS as
a whole.
273. The DH has been keen to present these as highly
exceptional cases of rogue managers and dysfunctional Boards.
However, there is evidence of widespread shortcomings in the way
that Boards approach patient safety. In March 2009, the HCC published
a study of how NHS Boards address patient safety as regards: making
safety a priority; placing items on agendas; and drawing on information.
The study involved 30 to 35 Trusts and was conducted by means
of focus groups and interviews with key people (there were no
visits or inspections). The key findings were as follows:
- Boards are paying more attention
to safe care, largely driven by concern for such matters as infection
control, and the aftermath of high-profile investigations.
- Control of healthcare-associated infection is
given a lot of attention by boards, and rightly so, but this is
disproportionate to the priority afforded to other areas of safety.
- Most boards receive reports on serious untoward
incidents, healthcare-associated infections and complaints, but
immediate targets or finances still tend to dominate their priorities,
and boards do not regularly receive a range of information on
different areas of safety (eg medicine management, suicides) or
of safety culture.
- Many of those consulted felt strongly that more
could and should be done to hear on a regular basis at board level
the direct experiences of patients.
- Most non-executive directors described themselves
as passive recipients of information on safety, with limited understanding
to challenge it effectively.
- Restructuring of services or the application
for foundation trust status tended to diminish the priority afforded
to safe care. However, such changes often prompted a review of
governance and reporting, with positive outcomes.[269]
MEANS OF IMPROVING BOARDS' APPROACH
TO SAFETY
274. There are a number of measures with the potential
to improve the approach of Boards to safety. Lord Patel, Chairman
of the NPSA, told us he thought steps needed to be taken to help
non-executive directors do better in holding their executive colleagues
to account:
I personally believe there ought to be a non-executive
director who gets appropriate training on what quality and safety
means in healthcare and that would be the person who takes the
role of governance in every trust, focussing on safety and quality.[270]
275. The Next Stage Review puts in place several
mechanisms intended to focus the attention of managers and Boards
on quality and safety, including the regular publication of "Quality
Accounts" and the use of "Clinical Dashboards".
At Luton and Dunstable Hospital we heard that the Board routinely
looks at "dashboard" data at its meetings.
276. The culture of an organisation may well be harder
to measure than other aspects of performance. We were informed
that several means exist of promoting a safety culture and assessing
progress in doing so. These include "tools" produced
by the Royal College of Nursing;[271]
and the Manchester Patient Safety Framework (MaPSaF).[272]
However, it is unclear how widely such tools are used or how appropriate
they are as a means of quantifying progress. At Luton and Dunstable
Hospital we heard that the Trust there uses the Safety Climate
Survey, developed by the Center of Excellence for Patient Safety
Research and Practice at the University of Texas.
277. In discussing the Health Foundation's SPI project,
Dr Jo Bibby mentioned some ways in which Boards could better discharge
their duties in respect of patient safety:
One of the approaches that the hospitals that
we worked with used was called Leadership WalkRounds. The idea
of that would be that usually two members of the board would visit
an area in the hospital on a weekly basis, different members of
the board. These were not spot checks, so it was not about trying
to find things that were wrong, it would be planned ahead, the
team would know they were coming. The idea of that would be to
start to have a conversation about issues around patient safety
in this organisation, the directors might say, "What was
the last safety issue that happened? Tell us about it so we can
understand how we would prevent that again. What could be the
risk that it could happen next?" When you go into the organisations
where they have been doing this, you get a real sense of recognition
that patient safety is something that the senior leadership are
paying attention to and that they are willing to act on system
practice to improve patient safety.[273]
278. Dr Bibby also told us about the example of Torbay
Hospital, whose Board:
will start every board meeting with an item on
patient safety, so it is sending some very visible signals there
that this is something that is a priority for the leadership of
the organisation.[274]
At Luton and Dunstable Hospital, we learned that
a quarter of Board meetings were specifically concerned with safety
and quality, and that these routinely began with the stories of
harmed patients told either in person or through recorded interviews.
This served powerfully to focus Board members' attention on the
consequences of providing unsafe care.
Closed Board meetings
279. Another area of concern is the tendency for
a significant number of Boards to transact all, or a substantial
part, of their business behind closed doorswith the public
and press barred from their meetings and Board papers not freely
available. At Mid-Staffordshire Trust, the Board conducted a lot
of its business in private before it became a Foundation Trust
and thereafter held all of its meetings in private. It has been
reported that at least two-thirds of Foundation Trust Boards meet
in private.[275] We
were told by Eric Morton, interim Chief Executive at Mid-Staffordshire
Trust, that Foundation Trusts can discharge their duty in respect
of public accountability through public meetings of Governors[276]
(we heard the same argument from the Chief Executive at Luton
and Dunstable Hospital). Mr Morton told us that at Mid-Staffordshire
Trust, which lacked developed Foundation Trust governance arrangements,
the Board had begun meeting in public again since the publication
of the HCC's report.
280. The Minister of State for Health Services told
us that the DH deplored Boards meeting in private and had written
to them stating that this should not be happening. He explained
that the Department had no power to force Foundation Trusts to
heed this, but the Government was considering legislating to give
the DH more power to intervene in Foundation Trusts over this
and other matters.[277]
WHISTLEBLOWING
281. An important measure of an organisation's safety
culture is how it treats "whistleblowing", i.e.
"Spontaneous reporting outside normal channels by individual
members of staff"[278]
as a last resort in order to draw attention to unsafe care. Managers
and Boards in NHS bodies have a duty to heed whistleblowers and
to afford them protection from victimisation for raising genuine
matters of concern. In theory, such protection exists under the
Public Interest Disclosure Act 1998; and is reinforced in the
NHS by executive guidance, issued in 1999, requiring appropriate
local policies and procedures.[279]
And this protection is also reiterated in the draft NHS Constitution.
Yet, in practice, it seems that many NHS staff fear the consequences
of whistleblowing.
282. This has been a contentious issue in respect
of the poor safety standards uncovered at Mid-Staffordshire Trust.
The Secretary of State for Health has referred to "the mystery
of Stafford being the absence of any whistleblower" despite
the existence of adequate legal protection for whistleblowers.
He has insisted that "I do not accept that nurses, and least
of all consultants or doctorsI have yet to meet a shy consultantwould
not come forward on such a serious issue because they were somehow
terrified, despite the protection of the law".[280]
However, fear of victimisation may well have been a factor inhibiting
staff from whistleblowing at the Trust.
283. Ms Ocloo, the mother of a harmed patient and
a WHO Patient Safety Champion, told us:
I think there is still quite a lot of stigma
attached to doctors who speak up or so-called whistle-blow. Doctors
should have an obligation to speak up and tell the truth. I think
we should do something more about trying to get rid of that stigma.
Those doctors get quite badly labelled and stigmatised. If we
get rid of some of that, then we might get more of a flow of doctors
who could come through who would not feel that their reputation
might be tarnished.[281]
284. The Royal College of Nursing told us about the
results of a survey of its members according to which:
- 78% of respondents said they
would be concerned about victimisation, personal reprisals or
a negative effect on their career if they were to report concerns
to their employers;
- 21% had been discouraged or told directly not
to report concerns at their workplace;
- 64% did not feel confident their employer would
protect them if they spoke up;
- 99% of registered nurses understood their professional
responsibility to report worries about patient safety but fears
about personal reprisals meant that only 43% would be confident
to report concerns without thinking twice;
- 71% said their employers had not taken immediate
action to resolve the situation after concerns had been reported;
- 35% said no action was ever taken by employers
after concerns had been reported;
- 45% did not know if their employer had a whistleblowing
policy.[282]
285. The Royal Pharmaceutical Society of Great Britain
indicated that the law on whistleblowing is not adequate:
In Denmark the law has been changed so that it
is now an offence not to speak up when things go wrong, but measures
to encourage whistleblowing need to be accompanied by strong measures
to protect whistleblowers from dismissal and blacklisting. We
recommend that the Committee considers whether the UK's Public
Interest Disclosure Act (1998) has been successful in encouraging
and supporting whistleblowing, and whether additional measures
are needed in this area.[283]
286. Dr Peter Daggett asked the Committee "to
codify the way that consultants and nurses can actually contact
the next layer up, the PCT or the SHA, because at present there
is no defined route of doing that". [284]
287. We found that in New Zealand a statutory body,
the office of the Health and Disability Commissioner, has the
power to investigate and act on complaints from health-service
staff (as well as from patients and members of the public, as
we have noted) where they are not satisfactorily resolved locally.
Conclusion
288. 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.
289. Boards too often address governance and regulatory
issues, believing that they are thereby discharging their responsibilities
in respect of patient safetywhen 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.
290. 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 Lord Patel's 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 look specifically at patient safety and patient
experience should be recommended to all Trust boards.
291. 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.
292. 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.
293. 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.
294. 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.
295. 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 1998Whistleblowing in the NHS"
be re-circulated to all Trusts for dissemination to all their
staff as a matter of urgency.
296. 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 HCC, Professor
Sir George Alberti and Dr David Colin-Thomé, and the likely
further 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.
268 Department of Health and NHS Appointments Commission,
Governing the NHS: A guide for NHS Boards, June 2003, pp 9
and 11 Back
269
PS 52A Back
270
Q 854 Back
271
Ev 209 Back
272
MaPSaF was described to us by the NPSA as "a tool to help
NHS organisations (bespoke guides for acute, ambulance, mental
health and primary care) assess progress in developing a safety
culture" (Ev 149). Back
273
Q 633 Back
274
Q 635 Back
275
"Private board meeting risks spelled out", Health
Service Journal, 2 April 2009 Back
276
Qq 96-100 Back
277
Qq 1056-1059 Back
278
Department of Health, An organisation with a memory, 2000,
p 50. The document notes that: "In one sense, 'whistleblowing'
can be seen as evidence of a failure to learn-people are far more
likely to pursue channels outside their own organisation if there
has been a failure to act on or even acknowledge concerns raised
internally. To many a perceived need for external whistleblowing
is in itself a sign that organisational culture is seriously awry"
(para 4.47, p 64). Back
279
NHS Executive, HSC 1999/198 The Public Interest Disclosure Act
1998-Whistleblowing in the NHS, August 1999 Back
280
HC Deb, 12 May 2009, col 672 Back
281
Q 193 Back
282
PS 44A Back
283
PS 78 Back
284
Q 967 Back
|