Five years ago, when Sir Robert Francis QC published his report of the Public Inquiry into the Mid-Staffordshire NHS Foundation Trust, one criticism that was made was that he failed to identify exactly who was responsible (and hence should be held to account) for the awful failings in care that occurred at Stafford Hospital between 2005 and 2008.
"What brought about this awful state of affairs? The Trust Board was weak. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention [….] These failures were in part due to a focus on reaching targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care."
Following the Francis Inquiry and its diagnosis of the terrible consequences of a board that failed in its duty to monitor, understand, and respond to warning signs about poor care, there has been greater scrutiny of NHS boards and the extent to which they lead their organisations in a way that prioritises the quality and safety of care. To this end, the NHS regulator the Care Quality Commission uses a ‘well-led framework’ to assess all NHS trusts and foundation trusts that examines each board in relation to: strategy and planning; capability and culture; process and structures; and measurement.
Indeed, NHS boards have a statutory duty to ensure quality and safety in their organisation, but there is a dearth of research evidence as to how best to do this and the effectiveness of different board practices. In 2014, the Department of Health’s Policy Research Programme commissioned a suite of studies to examine the response to and impact of the Francis Inquiry. One of these projects focused on the ways in which hospital boards had responded to the inquiry report, in particular in how they lead their organisation.
The two-year study was undertaken by a team from the Universities of Manchester and Birmingham, together with the Nuffield Trust. The report of this research Responses to Francis: changes in board leadership and governance in acute hospitals in England since 2013 sets out findings from a national survey of all NHS hospital board members in England, and case study research in six hospital trusts, including interviews and focus group discussions with patient, staff and board representatives, a survey of ward and departmental managers, and observations of board meetings. It builds on prior work on NHS boards and governance undertaken by the research team, including study of the links between board and organisational culture, and care quality and safety.
Our newly published research reveals that hospital boards report that they are placing a high priority on care quality and safety, and many invested significantly in nurse and medical staffing in the wake of the Francis Inquiry Report. However, such investments were coming under significant strain by 2016/17 as the effects of constrained NHS funding increases were being felt very acutely, and boards found themselves facing profound tensions in meeting their twin duties to assure care quality and try and balance the books.
Following the Francis Report, many trusts had revised their policies on handling and responding to complaints, and on the investigation, reporting and learning from incidents. Likewise, many had developed new and enhanced approaches to staff engagement, ‘speaking up’ (or whistle-blowing), something that we know from prior research is linked with a healthy hospital culture likely to enable safer and higher quality care. There was also a clear sense from our research that trusts had embraced and implemented the duty of candour advocated by Robert Francis as an essential approach to being clear and transparent with patients and their families when something has gone wrong with their care.
The assurance of quality was experienced by some hospital boards as a pressure, as the demands of multiple external regulators was reported to sometimes feel burdensome, threatening to distract from a focus on the actual work of service improvement. One respondent in our research described this as ‘regulatory throttle’. Another barrier to progress in implementing changes to the leadership of care quality was reported to be the perceived variable nature of middle management, and ward and department team-working.
Based on analysis of the data from across this study we concluded that the following can enable stronger and more effective board leadership of acute hospitals:
- Having a strong and effective human resource and organisational development function
- In-house programmes to improve governance, quality, safety and complaints handling
- A board that is able to sustain (in the eyes of staff) reliable, consistent and clear messages about core priorities
- A body of governors and patient representatives (or similar for non-foundation trusts) who are engaged closely in trust quality and safety work
- Using complaints and incidents as part of a wider programme of trust learning and review.
This research underlines the value of a "restless board" that seeks constantly to find out more, benchmark itself, do better, and check on prior concerns and actions. It also needs to provide stability and consistency of purpose in a turbulent and pressured NHS. Boards may do well to embrace the full repertoire of board purposes and mechanisms identified in prior research. Indeed, they need all the tools and support they can garner, for this new research suggests that boards find themselves caught on the horns of a dilemma, wanting desperately to prioritise care quality and safety, yet struggling in the face of financial, workforce and other pressures.