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Strategies for a stronger and more open NHS
It’s nearly a year since the publication of the Francis Report and at least six other reports have been published in the interim, including the Government’s initial response ‘Patients first and foremost’. We now have ‘Hard Truths’, its comprehensive response to the 290 Francis recommendations.
‘Hard Truths’ builds on the Government’s initial five key themes of preventing problems, detecting problems quickly, taking action promptly ensuring robust accountability and ensuring staff are trained and motivated.
The clear message is that patient safety and care is the responsibility of all within healthcare. It is understood that the Department of Health will review progress annually – something for boards to take notice of as there is a real will to ensure that lessons are learnt, and real and measurable change made. So how are management to make sense of and implement these changes – and those to be introduced over the coming months – whilst running complex and challenged organisations?
What is clear from the reviews such as the Berwick report ‘Improving the safety of patients in England’, is that boards need to address the loss of focus on “quality and safety as primary aims, inadequate openness to the voices of patients and carers, insufficient skills in safety and improvement and [inadequate] staffing for patients’ needs.”
Boards could do worse than consider what Berwick highlighted as the four keys aims for the future of the NHS: placing the quality of patient care, especially patient safety, above all; engaging, empowering and hearing patients and carers; fostering wholeheartedly the growth and development of all staff, embracing transparency unequivocally in the service of accountability, trust and growth of knowledge.
Understanding the system
All these themes are adopted in ‘Hard Truths’ – but in reality are unlikely to be overcome quickly and will need investment in systems, processes and most importantly, in people. The clear message is that in order to change, things have to be done differently.
It is imperative that management have a firm understanding and knowledge of the realities of the whole system and remain connected with those for whom they are responsible, including assuming responsibility to ensure that clinical areas are adequately staffed and safe. Everyone working within the NHS needs the skills to identify and help reduce risks to patients. To do this, management will have to provide the environment, resources and time to enable staff to acquire and deploy these skills.
A good example of how tricky this may be in practice is incremental pay rises. Since April 2013 trusts have been able, under ‘Agenda for Change’, to withhold increments from those staff whose performance is not satisfactory. Indeed, identifying such staff members will no doubt be one of the key metrics for judging whether organisations have put the necessary checks and balances in place, post Francis, to ensure that performance and patient care are up to scratch across their workforce. In theory this is laudable, and it might even save hard up trusts some money, if increments are not automatically awarded. In practice, though, how much progress has been made in implementing the necessary changes?
There is no national guidance on how to determine what satisfactory performance is. There is no nationally agreed process to follow, no steer as to whether there should be the right for employees to challenge the decision to withhold their increment at all, on appeal, via a grievance, or all of the foregoing. So, not an easy step to deliver for HR teams already stretched and seeking to deliver organisational change and support the attempted delivery of huge CIP targets across their organisations.
Boards would also do well to heed the clear messages in the Secretary of State’s opening to ‘Hard Truths’, to ensure their organisations have the ability to hear and see the patient effectively, be clear what their systems actually delivers, be more accountable and build a culture of compassion and care.
Key issues for boards include the need to respond pro-actively to a new system of fundamental standards to be launched by the DH which Francis had recommended, and which the CQC are expected to enforce and review, through a radically reformed inspection regime backed by a series of further criminal sanctions covering such matters as information and lack of safe care.
Boards need to emphasise the need for every individual within the organisation to play their part, noting that external regulators, the police, HSE and commissioners and patients will see this new environment as a way to hold the NHS to account.
Management will need to grasp the new metrics; how these are to be applied by regulators, patients and staff; implement mechanisms to gather key data, ensure they can meet the new inspection regime and understand what they need to measure and change to enhance patient care and safety. There will be a raft of new measures including mortality data, benchmarking, friends and family tests, responses to staff surveys and meetings with commissioners increasing the demand for transparent access to information and data.
A culture of openness
Whilst this is not the first time that there have been failures of care within the NHS, or recommendations made for change, what appears different is the appetite for change in the general public, allied to a political appetite to see change effected.
NHS boards will face a number of new challenges, such as the implementation of a statutory duty of candour, over and above that already in place with commissioners, through NHS contracts.
The risk is that a failure to be candid could lead to the organisation itself being liable for litigation costs. Boards will also need to have early knowledge of what goes wrong via an open and robust approach to accountability and self reporting. It will be necessary to have processes which are known to all staff and which protect whistleblowers from possible victimisation – in light of the changes made to the Public Interest Disclosure Act last year.
The board and its directors will need to have their skill sets reviewed to ensure they meet the new proposed fitness test and have the skills to ensure governance across the main themes of the report. Finally, they will have to be able to meet challenges from the CQC and/or Monitor in relation to the capabilities of the board and the organisation.
Organisations face stiffer sanctions with a will to enforce them. This is particularly so in relation to the provision of unsafe care following the creation of a new offence of wilful or reckless neglect on the part of individuals or healthcare providers, including the provision of false or misleading information.
Tracking patient data
Foundation Trusts will have to adapt to the far greater powers and involvement on the part of their governors, following on from reforms in the Health and Social Care Act 2012, with governors now able to summon directors, approve or be consulted on key elements and be a link to external regulators.
Boards need to grip key patient metrics including complaints, incident and claims data and make full use of an ever improving and evolving set of relevant data which are likely to be increasingly useful in identifying key issues.
This will require improvements in the gathering of data and a means to target keys areas such as falls or infection. It will require a focused investment, communication and engagement strategy to ensure every member of staff is aware not only of their professional and legal obligations, but their role in the provision of data continuing from the duty of candour. This will be crucial in order to meet the requirement of a website for patients providing up to date ward level data on patient safety, as a means of improving patient care.
There is now a real mood, and more importantly public and political appetite, for change, with a radically reformed NHS putting clinicians at the heart of commissioning and a willingness to learn and share experience. It is now up to the NHS to take the action. The challenge is in delivering this reformed structure in the cash-limited healthcare sector, whilst responding to an ever increasing publication of actions and expectations that require both legal and cultural change not just at the top, but throughout all aspects of every public sector body.