NHS Trust Boards need to be robust – concerns raised by Keogh report
Sir Bruce Keogh’s report reviewed 14 NHS Trusts which had high mortality rates over the last two years. The report identified specific failings at all 14 Trusts.
The review often found quality issues of which the NHS Trust Board itself were unaware. Whilst many Boards could point to improvements in quality checks, such as by doing walkabouts in the hospitals, review teams were concerned that Boards would too easily accept the assurances they were receiving and were not really listening to contradictory evidence or seeking more robust assurance. The review states that in some cases, the non-executive directors and chairs of the Trusts were not providing appropriate critical challenge to the management team or seeking independent assurance.
While some had very capable medical and nursing directors, this seemed not to be the case in all Trusts, and this was a key issue for several of them. Most Trusts reviewed were either struggling without a strong clinical leader in one or both of these key roles, or had experienced a capability gap in the recent past. This has to be a key priority for them.
A number of the trusts are geographically relatively isolated, or are spread across a number of sites which are some distance apart. Some Trusts reported that this makes it harder to attract a high quality workforce, and to fill vacancies with the best people.
Where the capability of medical directors and/or directors of nursing was questioned by the review teams, common concerns were:
• poor articulation of the strategy for improving quality;
• many trusts had findings from quality and safety reviews undertaken recently by internal and external parties but could not show a comprehensive and consistent approach to learning from these; and
• a significant disconnect between what the clinical leadership said were the key risks and issues and what was actually happening in wards and departments around the hospitals.
Five of the Trusts reviewed have not yet achieved Foundation Trust status, but of the nine that are, six were already below green on Monitor’s governance risk ratings.
A number of the Trusts have been undergoing mergers, restructures or applications for Foundation Trust status and many have needed to make significant cost savings. These issues may have diverted management time and attention from focusing on quality. This was a key factor raised in the inquiry into problems at Mid Staffordshire Hospitals NHS Foundation Trust. While the review did not find this level of distraction in the 14 trusts, it has forced quality of care to its rightful place at the top of the board’s agenda.
At each of the Trusts, the review found there were processes in place to ensure cost improvement programmes were not adversely affecting quality, but there was more for all the trusts to do to ensure these are applied consistently and monitored continuously.
This review is not completed, as there are tailored arrangements for following up and checking on progress. The new chief inspector of hospitals will prioritise a full inspection of the 14 Trusts during the first year of taking up his new role. This will lead to a formal rating for each hospital under CQC’s new inspection model.
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