On February 12th I attended a training day for NHS foundation trust (FT) governors, part of a programme branded GovernWell, run by the Foundation Trust Network (FTN). The content was superficially appealing, and the event made for a pleasant day out, but I thought it fell far short of what’s needed to train governors so that we can be effective in the role that’s envisaged for us.
Almost exactly a year ago, in February 2013, the Francis Report recommended, amongst other things, that (Recommendation 77):
“Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust’s services.”
In the body of the report one of the key themes was that (Chapter 6):
“Foundation trust (FT) governors have great theoretical power without great accountability – they are reliant on the goodwill of the chair and board, and there is little consistency in their role between FTs.”
And in particular (paragraph 10.201):
“Governors are a disparate group from a wide variety of backgrounds. While they are a valuable source of information about local views, they are unlikely to be able to assess fully the competence of the board or effectively monitor its performance unless they have adequate support, for which they are currently almost entirely dependent on the board itself. Pursuant to the obligation of FTs to provide appropriate training, steps need to be taken to enhance governors’ independence and ability to bring to light and challenge deficiencies in the services provided by FTs.”
These conclusions arose, in part, from evidence given by governors at Mid Staffordshire NHS FT to the previous enquiry, whose report had been published in February 2010. For example, one governor had said (Volume 1, paragraph 99):
“To be perfectly honest, it was a huge learning curve for everybody and I can’t say that it was an effective body at all…”
And another said (paragraph 100):
“We had pages and pages of what we were supposed to do, but I have to confess, I thought it was only just me that didn’t understand a word. But it wasn’t just me at all.”
In November 2013 the Government published its full response to the Francis Report, in which it accepted Recommendation 77:
“Working in partnership with Monitor and the Foundation Trust Network, the NHS Leadership Academy has commissioned the GovernWell programme, a new national training programme for foundation trust governors. The GovernWell programme is designed to help equip governors and non-executives with the skills they need to perform effectively, including improving their ability to challenge quality problems.”
So it’s easy to understand the intended purpose of the training — to enable governors to be more independent of their trust’s board, to ensure that we are not simply overloaded with information we don’t understand, and to equip us with the skills to discover and challenge any problems with the quality of the healthcare provided by the trust.
In these terms the training day was a complete failure.
The FTN is effectively a trade association for foundation trusts, and in that sense it represents the collective view of trust boards. Shifting part of the responsibility for training governors from individual boards to the FTN does little to help governors become more independent of boards. Rather, it institutionalises our dependence on them.
Far from helping governors deal with information overload, the training day reinforced the learned helplessness of governors overwhelmed by information…by further loading us with information.
And instead of equipping us with skills in relation to the quality of healthcare, the training day de-emphasised both skills and healthcare quality.
Core skills module
The event that I attended had the title “Core Skills” and it’s the introduction to five specialist modules covering aspects of governors’ role in more depth.
The day was divided into five sessions, which I’ll describe individually below. Unfortunately because of a family medical emergency I was only able to attend the two afternoon sessions, so my descriptions of the morning sessions will be a little skimpy, as they’re just based on the handouts and on what other governors told me. No one gave me the impression that I had missed anything of great importance, even though the morning sessions had overrun badly.
The overall objectives for the day were stated to be:
- To understand the framework within which NHS foundation trusts operate
- To understand governors’ statutory and non-statutory duties
- To understand the concepts and methods of holding the board to account
- To provide a forum for governors to meet and learn from each other
You can immediately see that there were no skills objectives at all.
Worse, “holding the board to account” is not a part of governors’ role. Since April 1st, 2013, governors’ role is only to hold non-executive directors to account for the performance of the board, not to hold the board to account directly.
The error is repeated on the next page of the handout, which attempts to list governors’ statutory duties. The first bullet point is:
- A statutory duty to hold the Board to account
Nope. That’s not to be found anywhere in current statute law, nor anywhere else in official guidance to governors.
This is an intriguing error, because it reflects the FTN’s view of some years ago, revealed in December 2010 in the Government white paper, Liberating the NHS: Legislative framework and next steps (p. 121):
The Foundation Trust Network argued that the aspiration should be for governors to “act in the interests of future generations as the local proxy for the public’s interest in [FTs’ assets and services] as tax payers and citizens”, and therefore it was right to “strengthen the ability of the governors as a whole to hold the board to account”.
But the FTN didn’t get what it asked for. The Health and Social Care Act 2012 only specified a duty of governors to hold non-executive directors to account.
The NHS: An introduction
The day began with a brief introduction to the NHS, including an outline of the structural changes brought in by the Health and Social Care Act 2012.
Two rather misleading diagrams attempt to show the structure of the system before and after April 1st, 2013, with circles or ovals representing organisations within the system. Here’s one of them:
The trouble with the diagrams is that the sizes of the circles give a misleading impression of the importance of the organizations. For example, commissioning support units (CSUs), which do no more than provide technical support to clinical commissioning groups (CCGs), are shown as much larger than the CCGs that they support, falsely suggesting that the CSUs are a very important part of the system.
Indeed, in the diagram shown here NHS England together with its regional offices, its local area teams and the CSUs take up nearly half the entire diagram — more than half if you include the Department of Health. This does not reflect the way the system works at all.
Furthermore, one of the major changes on April 1st, 2013, was that primary care moved from being locally commissioned by primary care trusts to being nationally commissioned by NHS England. But the diagrams show primary care remaining in exactly the same place.
Part of this session, I suppose, is a separate handout with the title “Where do Foundation Trusts sit within the NHS health system?” This is just a big glob of information about stuff. It looks hastily written. It doesn’t tell you where foundation trusts sit within the system with any clarity at all. Actually, FTs sit in different places depending on where you’re looking at the system from.
For example, if you look at clinical pathways (the kind of experience of the NHS that a patient with a particular illness will get), the system divides up roughly into primary, secondary and tertiary care with foundation trusts operating mostly in the secondary bit. A patient might experience this in terms of going to their GP (primary) who refers them to a specialist at the local hospital (secondary), who in turn refers them to a specialised regional centre (tertiary). The handout doesn’t tell you any of this.
Another part of this session, I suppose, is a little booklet with the title “Jargon Buster: Helping you navigate around NHS acronyms”. This, too, looks hastily written. Most of the entries aren’t actually jargon, some of them aren’t abbreviations (or acronyms, as the title calls them), and some of them aren’t even NHS. There are so many abbreviations in common use in healthcare that it’s very hard to put together a comprehensive list, but this one just hits you in the face as inadequate.
For example, ED is described as executive director or emergency department, but eating disorder is omitted. MRSA (methicillin-resistant staphylococcus aureus) is included but the equally troublesome Clostridium Difficile and VTE (venous thromboembolism), also known as DVT (deep vein thrombosis), are omitted. LA is described only as NHS Leadership Academy when it far more commonly means local authority. The King’s Fund is included (though without its apostrophe) while WHO, the World Health Organization, is omitted. The Mental Health Act 1983 is included (though without its year), while the equally important Mental Capacity Act 2005 is omitted. MI is described as a major incident affecting hundreds of thousands of people, rather than the more common myocardial infarction (i.e. “heart attack”), while SI (serious incident), the roughly equivalent SIRI (serious incident requiring investigation) and SUI (serious untoward incident), and “never events” are all omitted. HCA (health care assistant) is included while CPN (community psychiatric nurse) is omitted. NHS England’s LATs (local area teams) are included, but their QSGs (quality surveillance groups) are omitted. I could go on.
The governor and the FT
A session on the governance of FTs and the role of governors outlined what boards of directors, non-executive directors and governors do. It was good to see the statutory duty of directors clearly stated (with “corporation” in this context meaning FT):
“The general duty of the board of directors, and of each director individually, is to act with a view to promoting the success of the corporation so as to maximise the benefits for the members of the corporation as a whole and for the public.”
This outline of roles seemed generally OK. A minor niggle is that there is a reference to “non-NHS income”. This should always, or almost always, read “non-English NHS income”, as income from the NHS in Scotland, Wales and N. Ireland would have to be included. Gloucestershire trusts, for example, might conceivably have NHS income from across the Welsh border, and this would be treated as “non-NHS” income in England.
It was good to see some explanation of risk and risk management, but very disappointing to see that “assurance” was not well defined. It is, admittedly, hard to define in a way that distinguishes it from complacency.
A cartoon in the handout shows Dilbert’s pointy-haired boss with the caption:
It’s not clear what, if anything, this means for governors. It was surprising, too, not to see any acknowledgement of the Dilbert cartoon strip or its copyright owners, especially as some of the FTN’s handouts state on every page:
“This text is copyright and may not be reproduced without permission”
Assurance needs to be better defined, or alternatively the word shouldn’t be used at all in the context of governance. It cannot just mean that everyone thinks everything’s OK. Everyone thought that in Mid Staffordshire until a non-NHS group (Cure the NHS) came along and burst their bubble. The whole point of this training programme and all the rest is to move beyond everyone thinking everything’s OK.
Finally, a useful diagram of the process of holding to account shows a cycle of five activities: Listen, Question, Assess, Form a view, Feed back. It seems to me that governors usually omit the Assess and Form a view steps, often because their trusts don’t allow them the time, so that they have nothing useful to feed back. Thus governors tend to listen to lots of presentations and ask a few questions, and then the answers disappear into the sand…which is pretty much what happened on this training day.
Effective questioning and challenge
A session on questioning and challenging did contain something of a skills element, but the problem with “assurance” recurred, and there seemed to be continuing confusion about the difference between assurance and holding to account. For example, one statement about the role of the governor was that it:
“Is about question, challenge and assurance…”
Holding to account didn’t get a look-in here.
In a list of about a dozen sample questions for governors to ask non-execs or the board, there’s not one example of holding anyone to account. They are all soft questions asking for yet more information, ranging from, “How are we doing against planned goals and objectives?” to “How can we as governors help?”
Similarly, in a list of tips for effective questioning and challenge, there’s not one tip about holding to account or the performance of the board. They’re just things like “Prepare beforehand” and “Respect others”.
The conspiracy theorist in me concludes that the FTN, on behalf of the boards of its member trusts, is terrified lest governors start to ask questions that begin, “How do you account for…” and that, to quote the Francis Report again, “expose and challenge deficiencies in the quality of the foundation trust’s services”.
Finance and business development
A session on NHS finance and business development bombarded us with information about NHS finances. The emphasis was on how difficult it is for FTs to make savings and meet financial targets, and on how much worse this will get in future. There was far too much to take in, and it wasn’t clear which bits were the most important for governors to understand.
A peculiar table purporting to show the costs of emergency admissions to hospital in a couple of dozen trusts indicated that all of the general hospital trusts were providing this service at a financial loss, and most of them forecast continuing financial losses in the future. We weren’t told what this means in real terms. Were these FTs not paying their staff? Were they taking out loans that they wouldn’t be able to repay? Was the problem that they are being fined so much for discharging patients who are still ill? The presentation rushed on. There was much more to bombard us with.
Governors were mentioned briefly. We were told that governors have an important role. Yes, very important. Exactly how it’s important, and why, we weren’t told. We we given no examples of governors ever actually doing anything important. The presentation rushed on.
Eventually, when it ended, business development hadn’t really been covered, as far as I could tell. There was a strong sense that financial pressures will lead to change, but no sense of the mechanisms or directions of change or of governors’ role in those mechanisms.
For example, one direction that’s perfectly obvious to anyone who reads the newspapers is that the private sector and the third (“voluntary”) sector will play an increasing part in NHS service provision, reducing FTs’ income overall while introducing new service models that FTs will be able to (and have to) copy in order to compete. But nothing of this was mentioned.
Pausing to draw breath, the presenter rushed on to bombard us with information about quality. The statutory definition of quality was paraphrased as consisting of clinical effectiveness, patient safety and patient experience. (The law actually states it in a slightly different way — for example, it doesn’t use the word “clinical”.)
The very next presentation slide presented a “national picture of improvements over time”, listing eight areas where there had been improvements. The trouble was, not one item in the list related to clinical effectiveness.
Throughout the rest of this huge, rushed, presentation clinical effectiveness was consistently downplayed. One slide did contain some examples of “measures of quality you might expect to see”. Under the heading of clinical effectiveness only one or maybe two of the six items actually measured clinical effectiveness.
For example, the first item was waiting times. But waiting times don’t tell you anything about how effective the treatment you’re waiting for is. They may seem to have an indirect effect, because you might get worse or die while you’re waiting, but a service can be clinically effective (everyone who is treated recovers) at the same time as being administratively lethal (many people die while waiting to be treated).
A final page in the handout lists some examples of how FTs have engaged governors in quality issues. Not one of them describes how a council of governors is effectively challenging issues of clinical effectiveness. The nearest that governors seems to get is when individual governors sit on joint working groups within their FT.
Once again, the conspiracy theorist in me concludes that the FTN, on behalf of the boards of its member trusts, is terrified lest governors stray beyond softer safety and patient experience matters to ask awkward questions about whether the healthcare provided by FTs actually works.
On seeing this final page, I suddenly woke up to the fact that there had been no case studies at all in the rest of the presentations. We were given no actual examples of councils of governors taking effective action to hold non-execs to account or exposing and challenging deficiencies in their FTs’ services. Even on that final page, there were no examples of that kind.
It was also notable that there was no mention in this session on quality of either the NHS Outcomes Framework or the Health and Social Care Information Centre (where data on clinical outcomes is sent by FTs and where summaries of the data are published).
This training day was not exactly a waste of time. A very fine lunch and the opportunity to meet governors from other trusts are always welcome. But as training it was worse than a waste of time.
- It reinforced the idea that as governors our main role is to sit passively while information we barely understand is dumped on us.
- It subtly mislead us about our FTs’ business development environment, by downplaying the effect on the NHS of competitive tendering and non-NHS providers, emphasizing funding projections instead.
- It subtly mislead us about our role in questioning and challenging non-execs, by downplaying holding to account and emphasizing that we should ask for more and more soft information instead.
- It subtly mislead us about quality, by downplaying clinical effectiveness and emphasizing safety and patient experience instead.
- It glaringly lacked any case studies and actual examples of councils of governors acting effectively, reinforcing the idea that ineffectiveness is normal and acceptable.
- It carefully avoided imparting any skills. None of us ended the day able to do anything that we wouldn’t have been able to do if we’d just been put in a hotel meeting room and left to amuse ourselves.
Effective training for governors needs to be delivered to a high professional standard by experienced skills trainers who really understand the problems that governors face and who can demonstrate practical solutions to them with reference to real-life case studies.
This event appeared to have been delivered by amateurs who seemed quite bright and enthusiastic, and who’ve no doubt read and heard a lot of stuff, but who didn’t really know what they were talking about and missed the point of the whole exercise by a mile. Recommendation 77 isn’t being acted upon.