Letter to a friend, a non-executive director on the board of an NHS Foundation Trust

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It’s three weeks since Robert Francis published his report and I know you are really worried about the hospital: about nursing care, about the mortality rate, and whether, before you arrived, people left the trust having signed gagging clauses. Most of all, you are worried about staff and how you can convince them the board does mean to put ‘patients first’ when they look around and see that elsewhere in the NHS nothing seems to change and it’s business as usual.

If your hospital is anything like the ones I’m hearing from, managers are telling you it’s an angry place. I hear that patients and relatives have started to film interactions with staff on their phones whilst others are threatening to go straight to the press if they don’t see the director of nursing in the next ten minutes. The Care Quality Commission and the Strategic Health Authority are keeping the temperature at boiling point with unannounced visits almost daily and the commissioners are demanding to know every detail of what is happening in the trust.

I know you are concerned about the pressure staff are under, and don’t want to make it worse. But you worry about your own responsibility for the safety and quality of patient care in the hospital. What can you do?

My advice is to remember that you are the eyes and ears of the outsider but you have privileged access to the inside of the hospital. That is your value to patients, to the executives and to the board. Use it well but take your time – thoughtful reflection about what can go wrong and why is all too rare, and we need lots more of it at every level of the system. Read chapter 20 of Francis’ report and his excellent account of what a common culture looks like to guide your own inquiry into the culture of the trust. With your fellow directors, develop a medium to long-term plan based on what you find.

Commit yourself to a year-long schedule of informal visits to wards, clinics and departments throughout the hospital. Try to visit at different times of day and night and on different days of the week. Introduce yourself to the staff on arrival and then, quietly and unobtrusively, observe what is happening. You may think this is impossible: that managers will resent you and feel undermined, that staff will behave differently because you are there, that you ought not to disturb patients. Remind yourself when you need to that your role is different from the managers’, because you are not compelled to take action. You have a right and a responsibility to use your eyes and ears: sit or stand quietly to one side, for only a few minutes and you will be surprised at how quickly people forget you are there.

When you do so, you will see for yourself the welcome patients receive; whether they can see the name of the person dealing with them; whether and how staff introduce themselves. You will see if you can tell from the uniforms who is who, and what their role is.  You can look for the written information for patients that is available to staff on the wards; you can see the quality of the physical environment and feel the atmosphere.

Introduce yourself to patients and relatives – find out if they know who is in charge of their care and how they can contact that person should they need to. Talk to the staff – find out what they think of their area of work and of the hospital. What do they like and what frustrates them? What would they like to change and why, and what do they feel they can do about it?

In the course of your visits I can guarantee you will see things that need to change. But – unless you see something that puts patients at risk, in which case you have to report it immediately – don’t produce lists of things that need fixing after each visit. That will reinforce the idea that staff are not trusted to get things right on their own.

Approach the visits and periods of observation instead in a spirit of inquiry, not monitoring. Talk to your fellow board members about what you are doing, keep a journal and find out what lies behind the problems you see and hear about. Be patient and gradually the workings of the hospital will reveal themselves. Be persistent and word will spread that the board is seriously interested in the work of caring for patients and the conditions that make it possible.

Remember, cultures change gradually, not overnight. Choose carefully when to act. Be brave, and gradually staff who believe now that Francis’ talk of a culture of openness, honesty and no blame is a con, might just be prepared to put their trust in you and to take the first step towards real cultural change.

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Comment date
14 January 2015
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Andrew WALL

retired CEO/ university lecturer,
Ex Bath Health District/Birmingham University
Comment date
21 February 2014
Knowing what you don't know is a perennial problem for non executives and one we were addressing twenty years ago from Birmingham. So keep up the discussion even if we seem to be repeating ourselves.

Andrew Peel

Public Governor,
Central Manchester NHS Foundation Trust
Comment date
29 December 2013
Good points and an interesting read. As a new Governor of an NHS Foundation Trust I am consistently surprised at the absence of good advice in our roles. In addition there is very little mention in the media about Public Governors and our link to members.

Do most members of the public know there are ordinary members of the public like me who meet regularly with Non Exec and Exec Directors and hold them to account? In this changing culture how should the relationship between Non Execs and Governors develop? Are there any lessons to be learned from the Co-Op crisis in term of the role of membership and governance in the NHS?

Ramble over.

Raymond Chadwick

Consultant Clinical Psychologist,
Comment date
05 April 2013
Thank you Jocelyn for this thoughtful and finely modulated piece. It is without doubt the most perceptive and heartening response to the Francis Report that I have seen.
To stand any chance of changing culture and improving care, we need first to understand clearly the forces already at work - and not least the remorseless law of unintended consequences. Successive layers of protocol-driven care and quality assurance measures (despite the best of intentions) have steadily become an industry in their own right, eroding professional judgement and responsibility and distracting from the core task of looking after patients. We already have regulatory frameworks with professional and legal sanctions, which need to be applied effectively when behaviour is simply unacceptable. What we actually need now is a fresh and imaginative approach to service review and audit which instead of imposing more boxes to tick (with dire consequences for failure) seeks to re-engage with clinical staff in the meaningful and collaborative pursuit of doing things better for patients. Which after all is what most of them wanted to do when they embarked on their career.
Your letter is a powerful exemplar of how to put this into practice.

Jocelyn Cornwell

Director, the Poiint of Care,
King's Fund
Comment date
07 March 2013
Hi Sholom, Very good to read your comment/hear your voice.

I agree,patient s are willing to talk - many more than is recognised, typically. The task of making whole organisations, departments, teams and individuals receptive to what they say is one has to be tackled at all levels. Last year - in November, at the annual Kings Fund conference on patients' experience - we invited the CEO and a Patient Experience Advisor from Kingston General Hospital, Ontario, Canada, to speak about their hospital, where patients and carers sit on every single decision-making group. Leslee Thompson the CEO, told us that amongst other changes, this had resulted in members of the 'patient flow' committee being challenged when they referred to patients as "frequent flyers" , and the executive team having to question the assumption that it is desirable to 'pull' patients through the system, when it disrupts continuity of relationships, communication and care.
If every hospital in England had patients and carers on ALL its decision-making bodies, imagine what a dramatic impact that would have on the culture.

Lynne Phair

Independent Consultant Nurse,
Lynne Phair Consulting
Comment date
05 March 2013
How wise your words are Jocelyn. the culture any care setting can be gauged by the tiniest actions by staff. Learning to see what is really happening and what care and compassion is being delivered, is an art. If NEDs along side front line staff learn to see what is really there , the tiny acts of care and compassion that make the biggest difference can be used to celebrate good practice as well as highlight areas of concern. The Sit &See Tool developed in Sussex teaches anyone who uses it to see what is really there from the patients perspective and it is becoming a force for change.

Ken Pugh

Freelance project worker,
Comment date
03 March 2013
Perhaps the non executive director should give attention to how staff can contribute to the process of evaluating service quality. Francis does give credit to what staff said in his first report (the one before the public inquiry). But then he makes little of the contribution of staff thereafter. We need to think about a methodology so this can be consistent across services. Here's one approach: vimeo.com/38625072

Peter West

Comment date
02 March 2013
How many non-execs talk to patients? I did it but others, and managers, saw it as asking for trouble. But it should be done.

Mary E Hoult

community volunteer,
Comment date
01 March 2013
I have tried for years since 2003 to support the change from Acute Trust to Community in the form of CCGs which I do think is the way forward.The problem is that most of the Acute Trusts are overloaded with large unreported backlogs of patients who missed their 18 week slots which will make the CCG groups work very hard indeed.I do wonder now if the NHS Commissioning Board is being set up for all this to fail and in 12 months time private contractors will have to take over.The lack of accountability in relation to the Mid Staffordshire situation I think confirms my gut feeling.

Heather Henry

Member of the national executive,
NHS Alliance
Comment date
01 March 2013
Dear Jocelyn
Thank you for writing this blog. What you demonstrate here is values - something I think gets trampled on in the rush for targets.
The psychology of leadership is just as important as the practical management skills and techniques. I know the King's Fund understands
this well as it is built into their leadership programmes.
In response to Mary's comment above I think that Francis applies just as much to community and primary care. I agree with Mary that primary care in particular is often the sentinel and confessional for patients and communities and that attribute needs more closely harnessing by CCGs.

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