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

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.