Professor R EndacottProfessor R SheaffProfessor R Jones

Dr V Woodward

BackgroundFrom 1990’s, UK gov advocate the ‘public

firm’ model for public service providersNHS services are managed through a

distinctive Board membership & structurePre 2003, 2 types of Trust – acute and

primary carePost 2003: introduction of Foundation Trusts

operate under licence (independant regulator Monitor)

more accountable to local populationsless central control

NHS Trust Board

NHS Bodies

Clinical services

clinical issues to influence management decisions

Performance managementContestability

lead

ership

Previous studiesGreater clinical focus at NHS Trust Board

level will improve the range, quality or cost of clinical care (Davies et al 2000; Marshall et al 2003).

Nursing leaders in NHS Trusts often lack the skills, confidence and opportunity to ensure clinical and patient care issues are adequately discussed at board level (Burdett Trust for Nursing 2006).

Study Aims1. To refine methods for measuring the

concept of clinical focus2. To examine effects of Trust Board

membership on clinical focus3. To examine relationships between

clinical focus and organisational culture4. To examine relationships between

clinical focus and service outcomes

Design To meet aims 1 & 2, two phase designPhase 1: analysis of publicly available data

(board meeting minutes, biographies of Board members)

Phase 2: observation at Board meetings for at least 3 sequential meetings

Phase 1 was preceded by extensive work testing measurement of clinical focus

Contextual dataSteering Group – Directors/senior clinicians Different processes for clinical issues getting

to BoardTrend towards greater part of meetings closed

to the publicExtent of clinical discussion influenced by

major events eg C Diff outbreak

Measuring clinical focus2 major judgments:

what constitutes an ‘item’how to distinguish clinical from non-

clinical in a replicable manner

An item.. a discrete issue or topic raised by a Board member. It is defined by content: - a relatively clearly bounded content,- distinct from preceding and subsequent contents of discussion.

Defining ‘clinical’ items...concerning the direct provision to patients of physical or psychological care or diagnoses (not the organisation thereof).

Coding manual developed

Clinical Non clinical

Service design and standards

General board processes

Clinical ethics and governance

NHS Agenda

Clinical outcomes Finance

Referral rates and volume Organisational

Activity Staffing

Evidence based models Patient Feedback

Validity & Reliability Piloted through observation of Board

meeting and review of minutes (n=5 Trusts) - 2 clinical academics, 2 academics

Inter-rater reliability: signs of ‘rater fatigue’: unusually small number of codes per pageover-arching trends that occur constantly recurring categories in large

section of textMedian agreement across 25 sets of minutes

= 95.35%

Population and Sample In Feb 2008, 298 Trusts listed on Department of

Health or Monitor websites:150 Primary Care Trusts (PCTs)92 acute non-Foundation Trusts (non-FT acute)56 acute Foundation Trusts (FT)Goal: 35 sets of mins/type of Trust = 105Sample: 2 difficultiesAvailability of minutesAccessibility of minutes

Sample - availability

1. One additional FT had minutes available but >9 months old

Significant - Chi-Square 1.548, p=<0.0001

Type Websites randomly selected

Recent 1

minutes downloaded

% recent minutes not available

FT 56 35 36.4

Acute non-FT

38 35 7.9

PCT 38 35 7.9

Sample - accessibilityPCT and acute non-FTs:8.6% (6/70) required ‘search’ facility91.4% (64/70) accessed via max 4 menusMajority located in ‘About us’ sectionAcute FTsAll 56 sampled to reach sample size (35)51% (18/35) accessed via max 4 menusSome stated minutes could be obtained via

‘FoI’ Act, for which a charge may be levied.

Early resultsMean no of items(range)

Mean % clinical items (range)

Foundation Trust 36.8 (18-64) 12.91 (5.5 – 24)

Acute Trust 58.8 (30-100) 15.54 (3.6 - 38.7)

PCT 64.9 (52-90) 20.4 (6 .0 – 47.8)

Ethical challengesAccess to private part of Board meetings

– requires all Board members to consentLengthy process – personal introductionsOne outright refusal from Board Chair –

no reason given

Conclusions Significant difference in availability and

accessibility of Board minutes between Foundation/non-Foundation Trusts

Trends in data to date: Fewer items identified in FT minutesLower % of clinical items in FT minutes

Steering group input essential to understand context

Next stages …Survey of Board membersTeam Climate InventoryAnalysis of publicly available service outcome

dataExamination of relationships between

Board membership, Clinical focus, Organisational culture and Service outcomes