The public was horrified by the findings of the Alder Hey inquiry led by Michael Redfern QC, but there is a danger that the failure in governance between Alder Hey and Liverpool University highlighted in the report may be obscured by other findings.
1The Alder Hey report says: 'Mutual trust between universities and hospitals could have avoided the worst excesses. . . All witnesses agreed that such trust is essential for the future.'
The report says that both the trust and the university failed to apply audit or management systems in the unit. It identifies several major flaws of governance: 'Alder Hey and the university. . .
failed to supervise and performance-manage the new unit'; and, 'Alder Hey and the university failed to apply or follow up proper audit procedures and management system'.
The implication is that universities and trusts should combine to govern and manage their shared interests. The report suggests that in future all trusts and universities making appointments should draw up a single job description and agree a joint statement of aims 'against which the next appraisal should be judged'. This appraisal should examine patient care as well as academic criteria. Clinical academics have responsibilities to both bodies and should jointly monitor these.
One positive development following the Alder Hey report is that a review of NHS/university managerial relations led by the education secretary 'will look at issues raised by those staff such as Professor van Velzen employed on joint contracts accountable to both bodies'.
2The rationale for a review is very clear. The events at Alder Hey expose in an alarming way that in the absence of clear partnership arrangements accountability can become lost in a no man's land between the jurisdictions of either institution.
For many years, NHS and university bodies have pursued complementary strategies, informally pooling funds to provide posts in specialties that match the priorities of each. Because of the close alignment of interests this has made sense.
This philosophy of mutuality and financial tit-for-tat has existed for 80 years. One of the major causes of tension over the past few years is the pressure on organisations to limit this mutual approach. Increased service commitments on NHS staff have both squeezed their teaching contribution and put pressure on clinical academics, who, in some cases, are the sole providers of a clinical service in a trust. In maximising research profiles, universities have removed posts pivotal to NHS provision.
Interdependence is such that almost every action has an impact on the partner institution. For this reason, joint strategies are needed.
But over the past decade or so incentives have increased to pursue strategies that point in different directions. In both health and higher education, institutions have had to meet strategic and political priorities that are in conflict.
There have also been some calls to make this mutuality explicit, to try to cost the contribution of the trust to the university and vice versa. But mapping the financial flow across organisational boundaries has proved extremely difficult. Costing the contribution of the clinical academic to the university and trust is complex, but is only one - albeit major - strand of a knotty and tangled financial relationship. In sites where resources are embedded, costing is even more complex: how is the use of physical space and equipment to be costed?
A Nuffield Trust survey in 1998 showed local partners felt that the integrated ethos of the tripartite mission was being driven into history, and that managerial relationships between the two were not uniformly good.
3Alder Hey is an extreme example of this. The inquiry team found 'little evidence of the essential mutual trust which must exist between a hospital and a university'.
Partnership is difficult. Even where partners have put a great deal of thought into the ways they work together, their different accountability systems will pull them in different directions and towards differing priorities. This presents a paradox:
partners are interdependent yet independent organisations. Trusts and universities have different policies and performance measures.
The aftermath of the Alder Hey scandal will be bound to affect the managerial relationship between universities and the NHS. The Redfern report could change NHS/university relations beyond recognition and in future come to be seen as the catalyst for the widespread emergence of effective governance.How many UK institutions, if inspected today, would be confident of avoiding the kind of 'management failings' reported by the inquiry team?
The fundamental reason for strong governance is that both depend on the other to deliver their own mission. The trust cannot deliver clinical service without the service contribution of clinical academics, and the university cannot educate its students without the educational contribution of consultants. The university also needs the NHS to access patients for research purposes. Each is mutually dependent. This mutuality is not straightforward, the priorities of each are in inverse proportion: the trust is driven by service priorities, and the university by research and education.
Without a strong strategy to govern and mitigate what are inevitable tensions, the individual interests of each organisation will compete and tensions will be destructive. A joint approach to governance must go beyond liaison and consultation.
In a report published last year, the Nuffield Trust highlighted some successful mechanisms for organisational partners to approach collaborative governance of their common mission.
4The Redfern report talks about the importance of 'good faith' in organisational relations. It explains that it 'shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic'.
My discussions with senior managers in universities and university hospitals in the UK and during visits to the US and the Netherlands suggest that partnership must move beyond a culture of liaison and consultation. These are notions that reinforce separateness. The problem with organising on the basis of good faith is that governance becomes vulnerable to personal and immediate priorities. Partners need to recognise their common aims and combine as if a single entity to achieve them. This is not to suggest there is a single solution. Local circumstances should dictate local governance arrangements. But the absence of an off-the-shelf model must not prevent the development of effective governance structures.
At present, policy does not reward or provide incentives for local partnership. Local governance between partners will only be effective if there is strategic alignment between the policies of health and higher education.
In the main, efforts to develop the NHS/organisational interface have taken the form of concordats between the health and higher-education sectors. Policy-makers and advisers have been reticent about recommending models of governance or structures for academic centres.
A monograph published by the Nuffield Trust presents the case for a framework for NHS/university relations.
3A new framework is needed to provide a modern strategic context and to enable a variety of partners and perspectives to address all aspects of the relationship. Formal partnership is needed because the context of NHS/university relations is so complex, and interdependence and entanglement of interest such that it has outgrown a mere notion of liaison and consultation.
Given the pressures within each sector, it is practically impossible to maintain partnership through a loose notion of alliance.
The Nuffield Trust is consulting with partners to develop a UK-wide forum for university clinical partnership. The aim will be to determine a joint strategic commitment on shared interests, to explore complex issues, share information and best practice, and strengthen partnership. In recognition of the ways that the partnership is fast broadening beyond a traditional view of specialist centres, it will incorporate a range of disciplinary and provider perspectives.
Why is this issue so important? Effective governance of this relationship is crucial to national interests. It provides general professional education and specialised graduate training; takes the lead in biomedical, clinical and health services research;
and champions the application of new knowledge for the alleviation of suffering, rehabilitation of injury, and prevention of disease and premature death. These are national priorities and are vital to the current and future health of the nation.
In 1981, Sir Fred Dainton considered the interface between universities and the NHS to be 'the place where the future confronts the present'. The challenge is 'to make this confrontation productive rather than cause sterile and destructive tensions'.
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