On Tuesday October 2 I attended a development day — a conference, really — run in Birmingham by the Foundation Trust Governors Association (FTGA). There were some good speakers, and there was some informative discussion amongst governors from different NHS Foundation Trusts (FTs).
The conference was held in the Paragon hotel, a former workhouse converted to almost-grandeur. The photos on the hotel website look a little airbrushed when I compare them to my memory of the conference. As a conference venue it was mostly adequate, but as in so many of these places the sound system was unreliable and in one meeting room the constant roaring of fans drowned out conversation. When asked to turn them down, hotel staff turned on more fans.
Nearly a hundred delegates from FTs all over England attended, along with a few other people from the FTGA, Monitor and so forth. I was the only delegate from 2gether, and there was someone from the South Western Ambulance Service, but no one from Gloucestershire’s hospital trust.
Two breakout sessions gave us a choice of topics. I chose standards of nursing, and accountability and governance, missing the sessions on Monitor’s new role and governor’s new powers in the area of finance. Then two keynote speakers addressed the entire conference on the plans for publishing information about NHS quality, and on the relationship between FT governors and local authority Health and Wellbeing Boards. Most of the presentations can be found here, together with further notes on some of them: Past Development Days
Time to care?
In a breakout session on standards of nursing, former nurse Yvonne Sawbridge spoke of her distress at standards of care in the NHS as she started out on her career. She must be glad she’s left all that behind, I thought. She’s now a senior fellow at the University of Birmingham’s Health Services Management Centre. At one point she remarked:
Have you ever had anyone at home with ‘flu? By day three you want to strangle them! (Maybe that’s just because I’m a nurse.)
Well, yes, exactly.
A key finding of research into poor nursing care is that it helps if nurses go around asking patients if they’re OK, she told us. Doing this is now known as “intentional rounding” by former nurses who have become researchers. An audience member remarked that:
In my day you had to do that. It was part of the routine.
She proposed providing more individual support for nurses along the lines of the support that the charity Samaritans provides for its volunteers, and the professional supervision that’s common (or even mandatory) in some other professions. Some pilot sites are participating in research to find out whether these solutions work.
I thought these potential solutions were good ideas that would probably be beneficial, but the presentation didn’t explain with any rigour the connection between standards of care and support and supervision for nurses. It didn’t seem like the research would clarify the connection or provide a clear business case.
I was left with the impression that nursing experts are struggling to understand what really drives quality of nursing care. They have an uneasy feeling that it’s something to do with culture, but they don’t actually want to hire a social anthropologist or study social anthropology themselves, so they look for solutions that fit within the culture that they themselves are already part of and unwittingly maintain.
In discussion, the group I was in felt that governors could contribute to nursing quality by visiting the wards and talking to patients and staff. I was the only delegate whose FT doesn’t allow that. Another delegate had been in the same position until an adverse report by the Care Quality Commission (CQC) forced them to take nursing quality more seriously.
I pointed out that a lot of the nursing care provided by a mental health trust happens in the community, not on wards, making it more difficult for governors to get involved in that way, and I joked that I was grateful for the suggestion that arranging for an adverse CQC report could be the way forward.
Accountability and governance
The title of this session may sound utterly tedious, but the dynamism and breadth of knowledge of the presenter, John Coutts from the Foundation Trust Network (FTN), made it valuable and memorable. It would be good to have him run a training day for all 2gether’s governors, I thought.
The FTN is, as he put it, a trade association for FTs, although its members include other types of NHS healthcare provider too. The presentation was constantly interrupted by questions from the audience, which were answered in detail and with authority. Unfortunately this started to unsettle the presenter, who started to look at his watch with an irate expression whenever a question was asked. It started to seem that the presentation was getting in the way of a great discussion.
He emphasised that the relationship between a council of governors and the board of the FT must be based on:
respect, candour and trust
When this is not the case, he advocated that the council of governors should take the situation very seriously. Asked how far governors should go in looking for primary sources of information, he emphasized that it’s for non-executive directors to challenge the board, telling governors:
You should see challenge from non-executive directors.
He firmly believes that FT boards should constantly be aware of and manage risk, looking at their FT’s key strategic risks at every board meeting, and that ideally they should share their risk assessments with governors.
Discussing difficulties that some FTs face, he said he thought governors should expect assurances that everything is all right, backed up by evidence. I suggested that governors may sometimes receive assurances that everything is all right despite the evidence, and he again referred to respect, candour and trust, concluding that:
You can’t have a relationship based on fantasy.
Discussion continued after the session ended, on the frustration governors sometimes feel when they see things are going wrong in their FT but seem to lack any effective means to drive change. The presenter emphasized the council of governors’ ultimate power to remove people from their posts. I pointed out how impractical it is to threaten the use of ultimate power over day-to-day failings.
Tim Kelsey, director for patients and information at the NHS Commissioning Board (NHS CB) addressed the conference on his plans to improve the NHS’s transparency and public accountability by making detailed information about healthcare outcomes more available. He described two principles — transparency and participation — and he pledged:
- To make data from GP and hospital clinical records freely available from April 2013.
- To create an open source technology platform that anyone can use to access the data in innovative ways.
His presentation was fluent and confident, and it inspired confidence that he means what he says. He explained his own background in journalism, and his mother’s experience of being ostracized after becoming an NHS whistleblower, which led him to start Dr Foster to publish information on healthcare.
It didn’t, however, seem to me that he set his vision clearly in the context of the NHS CB’s overall strategic responsibility for the commissioning. I mainly hear about the NHS CB in relation to Clinical Commissioning Gloucestershire, and these plans for transparency seem only vaguely related.
On transparency he made it clear that he envisions a wide-ranging culture change that will make information much more freely available. Echoing John Coutts’ remarks about risk, he made it very clear that he thought FTs should share their risk registers with governors, and publish them.
On participation he made it clear that the NHS must really put the patient at the heart of the system — it’s not just about holding some public meetings:
We need to shift the value sets away from production and towards patient outcomes.
I asked whether mental health will be included in his plans, from day 1, and in answering that question his confidence seemed to collapse. He spoke of the lack of basic building blocks in mental health information, things that should have been done years and years ago, but agreed that:
…mental health can no longer be a Cinderella service, certainly not from an information perspective.
I also asked whether he felt governors and the public generally had the time, knowledge and skill to make sense of detailed data, and he agreed that this is an issue:
There’s no point in dumping data on people and expecting them all to suddenly become experts…
He plans to address it by launching something called Code for Health in April 2013, to teach people how to build their own apps for processing healthcare data. The idea comes from Code for America. He feels that big FTs should be encouraging interested people among their staff, governors, patients and carers to take up the challenge of making sense of healthcare data, and he thinks that in the future many people will have this kind of expertise:
I think this is going to be a vast new knowledge economy which will develop.
Responding to another question, he noted that the proposed new NHS Constitution will allow more data sharing, and that although there is a tension between localism and centralism, the NHS CB understands the need for standards without getting in the way of innovation.
I thought that the ideas in this presentation could turn out to be revolutionary, and that the NHS really will be very different in just a few years if data can be unleashed in this way. The presenter used the technology sector term “disruptive”, meaning that the old way of doing things will be completely overturned, and I found this possibility believable.
Health and Wellbeing Boards
John Wilderspin, national director for Health and Wellbeing Boards (H&WB) implementation at the Department of Health, addressed the conference on H&WBs and their relationship to FT governors. He had been speaking to FT chairs earlier in the day.
Part of his presentation was a standard overview of H&WBs, and their role in driving health and social care strategy down to local authority level, bringing the NHS and social care together, and aligning local resources to common objectives. Local authorities and the NHS will not have had such close ties since 1974, he said.
He asked us how often FTs’ councils of governors looked at their local Joint Strategic Needs Assessment, and pointed out that active engagement of local people is needed if big issues like health inequalities are to be addressed:
How often do governors look at the JSNA?
He was aware of the discussion amongst FT governors about H&WBs in the FTGA website’s forum. Some governors who contributed to that discussion had felt that FTs should be represented on H&WBs because of their important contribution to healthcare, but others (like myself) felt that healthcare providers, in general, should not be allowed to influence strategy.
I was quoted in the presentation as having written:
I am very dubious about allowing providers to influence strategy in that way…as a public Governor, that’s the opposite of what I want for my community.
Someone asked whether I had just been referring to private providers, but I clarified that the discussion had been about FTs, and that I did not want to see FTs using their special position to stifle competition from other providers.
The presenter’s view of all this was that H&WBs would not necessarily admit providers as members, although it was up to them, but they should certainly engage fully with providers. Membership is not required for engagement. He was also keen to promote the idea that FTs should consider what they can offer their local H&WB, instead of just having expectations.
I thought the development day as a whole was excellent, mainly because of the calibre of most of the speakers, who were not just giving standard marketing pitches and who understood their audience well.
The two keynote speakers were impressive, Tim Kelsey for his evident commitment to what could be ground-breaking changes in the way evidence will inform future public engagement in the NHS, and John Wilderspin for his research into the FTGA’s discussion forum and his thoughtful mediation in the controversy there.