The Francis and Keogh reports highlight the need for good governance and effective Non-Executive Directors in the NHS
First the Francis report and now the Review into the quality of care and treatment provided by 14 hospital trusts in England by Professor Sir Bruce Keogh have highlighted the crucial role played by Non-executive directors in the NHS.
Questions about standards of nursing care, above average mortality rates and low staff morale have been asked by the media over the last few weeks – increasingly turning the spotlight on the governance of the NHS.
Patients, carers, doctors, nurses and managers are concerned and anxious about the level of care they can either expect to receive or that they are able to deliver. The Care Quality Commission, the body which is supposed to provide an independent assessment of quality in NHS trusts, has been discredited over its failure to spot departures from acceptable standards of care in several high-profile cases and there is a degree of confusion in other regulatory bodies as they struggle to find their way in the newly transformed NHS.
NHS staff, already feeling the pressure of having to find £20billion worth of savings to meet the Nicholson challenge, are now having to deal with the added burden of having to reassure patients and carers that theirs is not a failing trust.
NHS Non-Executive Directors are the eyes and ears of the outsider with privileged access to the inside of the Hospital, Mental Health or Community Health services upon whose board they sit. Together with the Governors (in a Foundation Trust) or the Staff Council (in a Social Enterprise) they are responsible for ensuring that the trust is governed effectively.
Speaking on Quality governance the Keogh report says:
“Too often our reviews found quality issues of which the board were unaware. whilst many boards could point to improvements in quality governance processes (e.g. undertaking walkabouts in the hospitals), review teams were concerned that boards could too easily accept the assurances they were receiving and were not really listening to contradictory evidence or seeking more robust assurance. in some cases, the non-executive directors and chairs of the trusts were not providing appropriate critical challenge to the management team.”
One of the recommended actions from the report is that:
Monitor and the NHS Trust Development Authority should consider the support, development and training needed for Non-Executive Directors and Community, Patient and Lay Governors to help them in their role bringing a powerful patient voice to Boards.
So what makes a good NHS Non-Executive director?
- NHS Non-Executive Directors must have a clear understanding of their role and how they can most effectively serve their trust.
- They must ensure the trust is governed properly: that it complies with the right laws and regulations, that its strategies are robust, its business plans achieved and that stakeholder and patient interests are protected.
- Non-Executive Directors must be independent minded, have integrity and gain the respect of other board members. Despite their personal liability, they need to step back from the detail (having satisfied themselves that there is a robust management, information flow and performance management structure in place at executive level) and be prepared to look at the trust’s business from a “big picture” perspective.
- Time is an important factor. Most advertisements for NHS Non-Executive Director vacancies talk of a commitment of two to three days a month – the reality is often double that number. Especially now, with the spotlight on NHS governance, Non-Executive Directors should be prepared to spend enough time on the job to ensure that they are effective and well informed on the key issues faced by the trust.
- Non-Executives also need the ability to wade through papers and other statistics and elicit the knowledge they need to perform their role effectively without being overwhelmed by detail. In fact, detail is often the enemy of the Non-Executive Director.
- Chemistry with fellow board members is also vital. That does not mean bending over backwards so everyone gets along but rather conducting themselves in a mature and professional manner and being prepared to monitor the activities of the trust and challenge the performance of the organisation and its executive.
- Non-Executive Directors should keep in touch with fellow Non-Executive Directors to share best practice between meetings, as well as immerse themselves in the trust’s business in the early days, asking lots of questions before forming opinions.
- Assertive judgements or challenges based on ignorance or misinformation will not enhance the image of a Non-Executive Director and only damage their credibility.
- In terms of the board and particularly the executive team, the role of a Non-Executive Director is to offer advice, challenge and apply sound governance. The challenge is to do that as part of the team rather than appear as someone standing outside and criticising without an appreciation of the tough job the executive team has to do. The executive team must also be open and keen to take on board advice from Non-Executive Directors.
- The best Non-Executive Directors are those with strong influencing skills, good powers of judgement, insight and vision, and good listening skills. It is also important to be committed and enthusiastic about the trust and to inspire confidence. Showing that you are level headed will help boost credibility and respect.
- Good training is important in developing Non-Executive Directors – there should be a training programme in place together with personal development plans. This will help to identify each board member’s particular skills, how they can be used and developed and which skills are missing across the board.
Assuming you have all of the above critical qualities how do you then make sure that you are an effective member of the board?
The keyword is assurance – how do you know that what is being said at board meetings is the whole picture?
You need to triangulate the information you are receiving from a number of sources to give you a feeling of how the trust is performing – much of this triangulation happens outside the boardroom, which is why being a Non-Executive Director is so much more than just attending board meetings or reading the board pack.
As an NHS Non-Executive Director you should make it your business to visit every area of the organisation – hospital wards, clinics, departments and anywhere that services are delivered. Try to visit at different times of day and night and on different days of the week – especially at weekends. Introduce yourself to the staff on arrival and then, quietly and unobtrusively, observe what is happening. You may think this is impossible: that managers will resent you and feel undermined, that staff will behave differently because you are there, that you ought not to disturb patients. Remind yourself when you need to that your role is different from the managers’, because you are not compelled to take action. You have a right and a responsibility to use your eyes and ears: sit or stand quietly to one side, for only a few minutes and you will be surprised at how quickly people forget you are there.
When you do so, you will see for yourself the welcome patients receive; whether they can see the name of the person dealing with them; whether and how staff introduce themselves. You will see if you can tell from the uniforms who is who, and what their role is. You can look for the written information for patients that is available to staff on the wards; you can see the quality of the physical environment and feel the atmosphere.
Introduce yourself to patients and relatives – find out if they know who is in charge of their care and how they can contact that person should they need to. Talk to the staff – find out what they think of their area of work and of the hospital. What do they like and what frustrates them? What would they like to change and why, and what do they feel they can do about it?
Make sure that the trust executives are aware of and supportive of these visits. If you find that you are a member of a board which is uncomfortable with Non-Executives talking to staff, patients and carers then raise this as an important board matter. It is impossible for you to effectively discharge your duties as a director if you are not encouraged to find out about the culture of the organisation at first-hand.
For the most part, what makes a good NHS Non-Executive Director is pretty much the same as what makes any Non-Executive Director effective. The difference is that the NHS has the power to dramatically effect people’s lives much more than probably any other organisation in the country.
What makes a good NHS Non-Executive Director is the realisation that along with your fellow board members you are responsible for ensuring that the trust delivers the highest standards of patient care.
- Jeremy Hunt accused of turning NHS deaths into ‘political capital’ (guardian.co.uk)
- The Effective NHS Non-Executive Director – Oxford 16 July 2013 (david-doughty.com)
- Jeremy Hunt to send ‘hit squads’ into failing NHS trusts (guardian.co.uk)
- Statement to Parliament: Oral Statement – Sir Bruce Keogh Review (gov.uk)
- Press release: Jeremy Hunt sets out plans to tackle mediocrity and inadequate leadership in the NHS (gov.uk)
- Trusts await high death rates report (bbc.co.uk)
- NHS braces for onslaught from Jeremy Hunt in run-up to report on care failure (guardian.co.uk)
- Parties in row over NHS deaths blame (bbc.co.uk)
- Thousands may have died because of Labour NHS failings, Tory MPs claim (telegraph.co.uk)
- Live: Report into Tameside Hospital death rates (manchestereveningnews.co.uk)