NHS trust boards are more on the ball than they used to be, but there is much more to be done when risk management is preferred to risk prevention, writes Nigel Edwards.

The question I was asked by the public inquiry into the failings of patient care at Mid Staffordshire foundation trust was: “What effect have national policy and targets had on the ability of boards to create a positive culture?”

The targets and terror regime in the early part of the past decade meant that performance targets dominated the agenda of many organisations. The targets were not well aligned to what boards thought was important and this led to some major problems.

For example, very little attention was paid to venous thromboembolism, despite it being a bigger killer than MRSA. This type of tunnel vision is a well-known consequence of target regimes. A particular hazard during this period was that the chief executive had to guess which objective was the hanging offence that would get them removed.

The past few years have been marked by more things for boards to focus on and, despite many promises to the contrary, no particular reduction in the regulatory burden. However, it does seem this regime is less distracting and provides less opportunity for distortion than its predecessor.

High-profile scandals at Maidstone and Tunbridge Wells, Buckinghamshire and Mid Staffordshire hospitals have focused boards much more on issues of quality and safety. Looking at the minutes from trusts over the past 10 years, there has been a marked change in what boards talk about and how they operate. The calibre of board members has improved and the level of challenge seems to have increased. Boards now talk much more about quality, safety and patient experience than they did in the early 2000s.

There is further to go, however. The volume of paper has expanded substantially. Some boards have performance reports with large numbers of indicators and page after page of coloured graphs, and these are difficult to navigate and fail to cut through complexity.

Cycle of intervention

A recent report by the Institute of Chartered Secretaries and Administrators found too little time was spent considering strategy, there was still insufficient appropriate challenge within the board, there were too many items to note rather than for decision, there was still scope to improve the time dedicated to clinical quality issues and the acquisition and use of information on clinical quality was not sufficiently robust.

It is all too easy to blame external pressure for the shortcomings of boards, and good boards have generally been able to resist it. However, we have created a system in which once things start to go wrong there is a cycle of intervention and oversight which can often exacerbate the problem and leads to a narrowing of a board’s focus that can be dangerous for the organisation and sometimes for patients.

Organisations in difficulty receive a huge amount of regulatory and strategic health authority attention, which often has the appearance of being more about managing the risks to the overseeing organisations than fixing the problem. Frequent requests for information, progress reports and demands for meetings can create a dangerous distraction.

External pressure can be a problem, but it is too easy a scapegoat: what the leaders of organisations do is much more important. There are worrying signs that we still don’t have the right culture to create high-quality service. In particular, the risk factors that emerged in my interviews with chief executives and chairs and a review of the literature are:

  • the tendency of some organisations to want to be in the middle of the pack;
  • negative responses to bad news;
  • rejecting adverse judgements and attempting to explain away data that indicates a problem;
  • high levels of chief executive turnover;
  • a lack of curiosity about how the organisation compares with others;
  • a lack of willingness to ask for help; and
  • stage-managed board meetings.

Many boards and leaders can point to a range of positive practices designed to ensure that the board is fully sighted on quality, the right measures are in place to encourage a culture of openness and patient centredness. They focus on complaints, devolve power and they challenge themselves to improve.

And yet problems persist and the Care Quality Commission is able to identify areas of poor practice even in well-managed trusts that focus on the right things. Systems of governance and assurance can only take you so far. High-quality supervision exercised by ward managers will take you further. But we also need to pay attention to the fact that caring for patients who are demanding, dying or have dementia is emotionally draining and anxiety provoking.

Without proper support, staff can become dissociated from their patients and stop caring. Approaches for dealing with this have been piloted by the King’s Fund, but clearly most people are more comfortable talking about the mechanics of the system rather than how to create ways to deal with these difficult issues. But in this area, opting for the comfortable path is one of the sure signs that you are about to get into trouble.

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