Patient Safety - Health Committee Contents

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 safety—despite 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]


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 doors—with 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]


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 doctors—I have yet to meet a shy consultant—would 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.


    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 safety—when 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 1998—Whistleblowing 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

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