Imagine sitting through a board meeting at Tesco. The meeting lasts three hours and at no time do chair Sir Terry Leahy and his directors talk about their customers or how satisfied those customers might be with the products and stores. It's a ridiculous notion, isn't it?
Yet this is exactly what is happening at some NHS trust boards. The boards discuss organisational change; they talk at length about outputs and financial targets, but far too few of them spend enough time at their meetings talking about their core business - the care and treatment of their patients.
The NHS is not a supermarket but it is a business, one that is funded by its key customers and deserves to be managed for their benefit.
Management too often blames the pursuit of targets as the reason for virtual abandonment of care and compassion. As trusts move to payment by results, the central issue will be the quality of care provided: complications cost money and create anguish. In a competitive world, organisations cannot survive on targets or finance alone. Just like a supermarket, customers will go elsewhere if NHS trusts fail to deliver what they want. Conversely, if you deliver a high-quality service in a well-managed and led environment, targets and finance will be easier to achieve.
Good care is good business. Well cared for, satisfied patients get better more quickly and leave hospital sooner. So how do we return care and compassion to the centre of management responsibility? How do we bring the concerns of the bedside to the boardroom?
It has been naively assumed that the 1.3 million people employed in healthcare in this country, in particular the 400,000 nurses who should be the standard bearers of care and compassion, would automatically understand the consequences of the seismic changes required by a demand-led health economy. A focus on care would continue and individual leadership, innovation and enterprise would swiftly replace the old regime of command and control.
But the language of the new order has been alienating for clinicians. Many simply have not been given the time, support or skills to equip them for this new world.
Widespread concerns about the quality of patient care, plus changes in health and healthcare, have caused many of us to question the strength, capacity and expertise in leadership - particularly nurse leadership - that we have now and which we can expect in the future.
Earlier this year the Burdett Trust for Nursing charity commissioned a study on the business aspects of patient care and the implications for the clinical professions and their boards. Who Cares Wins: leadership and the business of caring, carried out by the Office for Public Management, was based on the views of more than 200 healthcare experts, including senior nurses, gathered through surveys, interviews and workshops. It concluded that nursing leaders within trusts often lack the skills, confidence and opportunity to ensure that clinical and patient care are adequately discussed at board level.
In a companion study designed to back up the OPM findings with evidence-based research, Plymouth University researchers studied a representative sample of trusts. They found that 14 per cent of the items minuted at board meetings directly concerned clinical issues, with a variation of between seven and 22 per cent in a year for different trusts.
The OPM report starts from the important premise that the business of caring is a whole-board issue and argues that if a more market-driven health system is going to deliver a new NHS, patient satisfaction and customer care need equal ranking on board agendas with finance, targets and outputs.
Nurse leaders are well placed to lead the business of caring on their board's behalf, but the report makes it clear that there are also critical organisational factors that need to be put in place such as how the 'business of caring' will be led and managed, with clear accountability-seeking and acting on patient opinion.
What is really encouraging about the report is that it shows a significant body of nurses want to be in the forefront of change and want to be the leaders of a return to care and compassion.
However, creating the exceptional leaders and boards that will place patient experience at the heart of healthcare is critical, and the report makes important recommendations about how this can be achieved. For example, through creating a language and measures for the 'business of caring' and breaking the mould of traditional patterns of delivery.
The Plymouth review seems to support the perception that clinical patient care and experience issues from a small proportion of board agenda items.
It identifies two key themes for trusts with a higher clinical content on their board agendas: first, the chief executive linked clinical issues to all developments and, second, non-executive directors questioned trust board executives in an open manner and participated in subcommittees.
Other characteristics included: the presence of clinical directors and additional clinical staff at a proportion of board meetings; a more open attitude towards the public, including taking questions from them; evidence of liaison with social services; and infection control issues being discussed.
We face a golden opportunity to rebalance the public debate about healthcare. By putting the emphasis on improving health and delivering a more personalised form of healthcare, managers, clinical leaders and politicians can rekindle public confidence in the health service.
But all we have now is a report. Reports have a tendency to be read, tutted over and then put on a shelf to gather dust. This is not the outcome the BTN wants. So last week around 60 leading healthcare opinion formers gathered in London to discuss the results of these studies and what action could be taken to address the concerns raised. A healthy debate drew the following main conclusions:
- Executive and non-executive board directors need the skills and information to question the impact their trust is having on patients' experience. The board of NHS Direct, for example, listens to taped conversations of both good and poor performance in call-handling to stimulate debate;
- While caring is a whole-board responsibility, there needs to be a clear accountability for care at board level and space in the agendas for effective debate;
- If the language of business has been alienating for clinicians, a new lexicon must be found to describe the effect of caring on the financial bottom-line;
- Real-time measures are needed to enable clinicians and boards to understand the impact they are having on patient care. In the wake of the inquiry into maternity services in North West London Hospitals trust, new measures of quality and outcome have captured the imagination of nurses and midwives, and revitalised a demoralised workforce;
- Although in the main caring is the responsibility of the providers, it is essential that the commissioners clearly set out the range and standards they require, and measure whether they are delivered in practice;
- Nurses should be taught to understand the finance of care so that caring can be calculated in pounds and its value made explicit;
- A zero tolerance policy should be adopted by boards in terms of making it explicit that all clinicians, whether nurses, doctors or other professionals, are accountable not only to the users of the NHS but also to their boards for quality of provision.
Action on all these fronts requires backing from a number of key players and, although government support is essential, the required change would not be best achieved by a top-down initiative.
The best way to achieve the culture changes needed - in attitude and individual confidence - and to get them firmly embedded is by way of a groundswell of support across the whole healthcare system.
Last week's meeting was the first step. The NHS Confederation will follow up this theme with members in a seminar in November and the BTN is committed to backing any reasonable initiative that addresses this critical issue.
This report will not sit on a shelf. We must ensure that the business of caring and compassion becomes, once again, inculcated into the culture and management fabric of healthcare in this country.
S ir William Wells is chair of the NHS Appointments Commission and chaired the advisory group for the OPM study. Sue Norman and Professor Mary Watkins are both trustees at the Burdett Trust for Nursing. Copies of both studies are available on the BTN website at