Defending standards in a time of austerity

The governance of the NHS is probably not an obvious spectator sport, much less one you would thinking of taking part in.  (What does it mean, even?)  But we really should be pulling on our boots and getting ready to run onto the pitch because, quite literally, it’s a matter of life and death, and our team is struggling.

Governance describes the ways in which an organisation ensures that it performs well.  Derived from the Greek verb ‘to steer’, it covers all those systems, processes, policies and procedures which keep the organisation true to its purpose.  In simple terms, it can cover both internal elements (how a Health Board discharges its own responsibilities) and external (the impact of bodies such as Inspectorates on the Health Board). 

All are now in question following the events in a fairly average English hospital in Mid Staffordshire in the middle years of the last decade.  Patients were – in the words of the subsequent public inquiry – ‘routinely neglected’ by an organisation ‘preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care’[1].  Some estimates suggest that a staggering 1200 patients may have died as a result of this regime presiding over the hospital unchecked for more than four years.  And this was not an isolated asylum where few people saw what was going on: this was a busy general hospital, with thousands of staff, patients and visitors going through its doors every day.

One witness to the public inquiry recounted his experience as a patient:

‘In the next room you could hear the buzzers sounding.  After about 20 minutes you could hear the men shouting for the nurse, “Nurse, nurse”, and it just went on and on.  And then very often it would be two people calling at the same time, and then you would hear them crying, like shouting “Nurse” louder, and then you would hear them just crying, just sobbing, they would just sob and you just presumed that they had had to wet the bed’[2]

An isolated aberration?  Not in the view of the House of Commons Health Committee:

‘Several recent investigations have shown in detail how senior managers and Boards have failed in their most basic duties as regards patient safety, with disastrous consequences.  In each of these cases, patient safety was found to have been crowded out by other priorities, including the meeting of targets, financial issues, service reconfigurations…’[3]

But this all relates to England: Wales hasn’t had such a scandal for decades: things are different here?  Maybe.  But the NHS in Wales faces its worst financial squeeze ever in the coming few years: can we be sure that massive pressures to balance the books couldn’t have a similar impact here?

At a minimum, we need to take stock of our governance arrangements in NHS Wales.  The picture is currently quite complicated.  Health Boards and Trusts are in pole position on governance, since they actually provide the services.  Their governing Boards – made up of executive directors (employees) and non-executives (appointed by the Minister) – have access to all the information, and can have no greater responsibility than for the safety of their patients. 

But there are many challenges for those 15 or so people.  One is actually knowing what is going on in an organisation that employs as many as 18000 staff, across many hospitals.  How can you be sure, as a Director, that you’re measuring the right things?  Another is making acceptable trade-offs.  How low should staffing levels get, or how many patients should you treat, before the risk becomes unacceptable?  This is particularly important when you have a statutory obligation to balance the financial books at the end of the financial year, but quality of care is far less easy to define, let alone measure.

If they get it wrong, there’s the classic question: Quis custodiet ipsos custodes? Who will guard the guards?  There are various external bodies whose job this is, including Healthcare Inspectorate Wales, Wales Audit Office, Care and Social Services Inspectorate Wales, and a host of inspectors with specific roles in relation to health and safety, mortuaries, information and so on. 

And then – unique to Wales – are our eight Community Health Councils (CHCs).  Their role is to bring a patient and lay perspective to all these issues, to spot what experts don’t see, and to ensure that patients and the public get a good deal from their healthcare.  Welsh Government is currently consulting on how CHCs should develop to fit this new world, based on a review which colleagues and I recently carried out[4].

This is where the sport analogy comes in.  The eyes, ears and intelligence of lay people should be a crucial component in a fit system of NHS governance in Wales: we all need to be on the pitch (at the least, virtually).  At one level, it’s a matter of logistics – the more people the better.  At another, it’s about opening up the NHS to the shareholders – all 3 million of us in Wales.  The NHS is huge, complex and often obscured by jargon and mystique, and sometimes beset by self-interest.  If we could mobilise patients, carers and potential patients – i.e. all of us – to share our knowledge and views, that would a powerful aid to those 15 or so Directors sat around the board table in each LHB each month.  We need a multiplicity of ways of getting this intelligence: social media, the internet, simple things such as routinely and sensitively asking every patient to say what they found good and bad, collecting patient stories, and a host of alternatives, so that everyone can contribute in the way they find convenient.

There are probably four governance functions that must have an element of independence from the provider of services (the LHB or Trust).  First, individual patients who wish to complain must have easy access to effective and independent advocacy: for many people, complaining about the care you have received is too daunting even to try, without help.  Currently, about 10% of complainants to Health Boards are supported by an independent advocate, employed by the CHC.  Second, the plans of LHBs must be subject to scrutiny from the perspective of the local public and patients.  LHBs should do this as part of their planning, but probably shouldn’t be left to do it alone.  Third, we need lay people to monitor service provision, from the perspective of what matters most to patients, and without fear of displeasing your manager.  Finally, we need to provide a voice for the voiceless: sections of every community who will never, for whatever reason, wish to engage directly with powerful public bodies, but whose health needs are probably amongst the greatest.

We need to be clear about who should do which of these.  For example, what is the role of local government?  It has a democratic mandate, it has the resources to quiz and investigate, and it has massive local intelligence.  Should we in Wales – as in England – ask local government to play a scrutiny role over the NHS?  Or the third sector: what is its role in providing a voice for the voiceless?

These are complex, but crucial questions.  We have to be sure that we have got a robust, efficient and proportionate system of governance for our NHS, that ensures the active involvement of patients and the public. 

The NHS in Wales is aiming to be ‘world class’: to have services best suited to Wales but comparable with the best anywhere.  What does that mean for patient and public governance? 

[2] Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009, p53

 [3] House of Commons Health Committee (2009) Patient Safety p86


The above text  is from an article in the Winter 2012 edition of the Institute of Welsh Affairs journal, ‘Agenda’, by WIHSC Director, Professor Marcus Longley


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