news focus

The National Institute for Clinical Excellence starts work today, but many trusts are just not geared up for clinical governance, according to an exclusive survey of board members by HSJ and the Health Quality Service.

Half of all chief executives, chairs and clinical board directors lack confidence in their own trust's arrangements for clinical governance, according to a major survey on the eve of the government's quality reforms.

Less than a fortnight after health secretary Frank Dobson said that managers who failed to deliver on clinical governance would have to 'leave the NHS', it found high numbers of trusts failing to meet basic service standards (see box below).

It suggests that many patients are sent home in breach of hospital discharge plans, some trusts are still not checking references for new staff, and chairs are often out of touch with what is happening in their organisation.

Nearly 500 trust chairs, chief executives, medical directors and chief nurses took part in the survey, which was conducted by HSJ and the Health Quality Service. Together they represent 27 per cent of everyone in those posts.

The results, according to HQS director of development Andrew Corbett- Nolan, 'paint a picture of a service lacking in good quality information and boards bereft of confidence in the business they are supposed to be running'.

He adds: 'It seems that even in areas where the media have hung their colleagues out to dry, some trust boards have just not taken the hint.'

A report on the survey produced by Mr Corbett-Nolan and colleagues at HQS says that quality work to date has been 'driven through occasional briberies (ring-fenced funding) and individual interest'.

It adds: 'There has been little in the way of reward or incentive for taking up the quality mantle, other than the feeling of a job well done.'

But, it says, 'a few high-profile disasters' have now focused attention on the issue, and the launch of the clinical governance initiative has 'gone a long way to sharpen up thinking'.

'Anecdotally, we were picking up real concern - even a degree of fear - about the quality systems trusts had in place.'

The HSJ/HQS survey confirms that impression - with up to half of each group lacking confidence in their own clinical governance arrangements, and substantial minorities concerned about controls assurance (see figures 1a, 1b, 1c). 'These figures, to us, make disturbing reading,' the report notes. 'They demonstrate a fundamental lack of confidence in the arrangements many trusts have in place to cover the main responsibilities of the board.'

Respondents were also asked what information was reported regularly to the board (see figure 2). The answers confirm the view that directors get a lot of information on finance and waiting lists, but little on staff and patient issues.

The HQS report further breaks down responses by job title, noting 'differences in perceptions, or is it memories?', and gives data on areas where respondents said they did not currently get information but would find it useful.

The report reveals that trust chairs are more likely to believe their board gets regular reports on waiting lists, staff and patient satisfaction, near misses, risk management and litigation than other board members.

It also shows chief executives and chief nurses are considerably more likely to believe their board gets regular reports on clinical effectiveness than either chairs or medical directors. 'Comparing the two tables some puzzling facts emerge,' says the report.

It points out that reports from the Audit Commission and National Confidential Enquiry into Perioperative Deaths have been noting problems with clinical records, leading to poor patient care and litigation, for years.

'However, it would appear that nine-tenths of trust boards do not systematically receive information on this matter, and less than a quarter feel that it would be useful to do so,' it says.

'A similar pattern emerges for failed discharge... The costs of failed discharge for patient and trust alike are huge, and yet this does not seem a matter on which most boards receive information or feel it would be useful to do so.'

The report notes that boards have been clearly told to take responsibility for clinical governance.

'It is hardly likely in the event of a serious failure in clinical quality that boards will be able to absolve themselves of responsibility. There will be heads on spikes.'

But the survey indicates that trust boards are not currently receiving much of the information that they need to reassure themselves.

It goes on: 'More surprisingly, this lack of information is again apparent in areas where there have been some very public failures... A sizeable number of board members just do not know whether or not they have a problem.'

Feeling the Pulse: quality improvement and assurance in the NHS. Health Quality Service, c/o King's Fund, 11-13 Cavendish Square, London W1M 0AN.£15.