The Transparency of Trusts

The Transparency of Trusts NHS Foundation Trusts and Information Sharing

Dr. Geoffrey A. Walker January 2015

The Transparency of Trusts Dr.Geoffrey A Walker 2015 1

CONTENTS

Executive Summary 2 Introduction 3 1. The 3 Point Assessment 3 2. Key Findings and Analysis 3. Summary and Conclusion Notes References

4 10 11 12


Executive Summary The transparency of 146 NHS Trusts in sharing information on the organisation in terms of ‘the perceived quality of intentionally shared information from a sender’ (Schnackenberg & Tomlinson) was surveyed, analysed and evaluated between the 1st of September and the 31st December 2014. During this period, a 3 point assessment methodology was utilised to assess and evaluate transparency. An examination of online transparency revealed that a substantial number of Trusts (19%) appeared to be failing to meet the legal requirements of the FoI Act (2000) by not providing a publication scheme. Some Trusts provided online access to a disclosure log of FoI requests (22%) but a substantial majority failed to provide information in this format (78%). A relatively small number of Trusts could be considered as transparent in their attempts to share organisational information in an accessible format (20%). Overall, responses to a FoI request were varied in their nature and they varied in formats where information was provided. Where there was a failure to provide information, reasons given for inability to meet the request was questionable in some cases. The administration of FoI requests is a particular area of concern. There is considerable variation, between Trusts, on the managerial level at which FoI requests were handled. It would appear that all Trusts were failing to make Monitor’s ratings on Trust governance and services visible on their websites. In the interests of organisational transparency, all Trusts should: • publish their Publication Scheme online; • provide online access to a Disclosure Log which details responses to FoI requests; • provide responses to FoI requests, where appropriate, in a format readily available for further analysis, for example, in an Excel spreadsheet; • review how they respond to FoI requests and the level of responsibility within the organisation at which this is undertaken; • and, finally, publish, on their homepage, the current Monitor rating for governance and continuity of services and an explanation of the assessment.


Introduction The aim of this report is to evaluate the ability of Trusts to share information in a culture of corporate ‘transparency’. As large organisations, Trusts are encouraged by NHSEngland to be ‘transparent’ in how they manage information. NHSEngland has stated that ‘absolute transparency is the key to driving improvements in standards of care’. A definition of transparency, however, is not given in any of the literature published by NHSEngland [1], so, for the purposes of this report, transparency will be defined as: "the perceived quality of intentionally shared information from a sender" (Schnackenberg & Tomlinson). As such, information should be subject to a defined process of openness, communication and accountability which can be monitored and evaluated for its effectiveness. As a principle, Trusts have a duty to act visibly, predictably and comprehensibly to promote participation and accountability. Simply making information available is not sufficient to achieve transparency. Large amounts of raw information in the public domain may breed opacity rather than transparency. Information should be managed and published so that it is: Relevant and accessible: information should be presented in plain and readily comprehensible language and formats appropriate for users. It should retain the detail and disaggregation necessary for analysis, evaluation and participation. Timely and accurate: information should be made available in sufficient time to permit analysis, evaluation and engagement by relevant users. Information should be managed so that it is up-to-date, accurate, and complete. The survey was undertaken, over a four month period, between the 1st of September and the 31st December 2014. During this period, a 3 point assessment method was utilised to assess and evaluate transparency which consisted of:

1. evaluating responses to Freedom of Information (FoI) requests; 2. examining on-line transparency; 3. investigating Monitor governance performance criteria.

The 3 point assessment methodology was designed to allow evaluation of information provided against criteria of transparency, relevance, accessibility, timeliness and accuracy. 1. The 3 Point Assessment NHS Foundation Trusts were assessed on three areas:

• On-line transparency

Under the conditions of the FoI Act, NHS Foundation Trusts are obliged to publish a publication scheme. Some Trust also published a disclosure log of FoI requests. Trusts were assessed as to the production an online publication scheme and a disclosure log. If both were visible, on their web site, they were given a rating of ‘transparent’. Some Trusts, however, had taken a further step, in terms of transparency by publishing the responses to FoI requests online.

Responses to Freedom of Information (FoI)requests The Freedom of Information Act (2000) applies to most public authorities and governs access to non-personal corporate information.


The Act sets out three main provisions which are that public authorities: 1. inform a person making a request whether we hold the information of the description specified in the request; 2. communicate the information held to the applicant unless an exemption exists; 3. adopt and maintain a publication scheme (information regularly published by the organisation). The Information Commissioner, responsible for monitoring and enforcing compliance with the Freedom of Information Act 2000, has drawn up what is called a model publication scheme for all public sector organisations. The Commissioner has also published a definition document for NHS organisations which sets out in some detail the minimum expectations.

‘Please could you provide a list of all service contracts awarded for what and to whom during 2013/2014 including maintenance, domestic, clinical, administrative, medical, care, consultancy and any other services?’

Monitor’s governance and continuity of services performance criteria As the sector regulator for health services in England, Monitor's job is to make the health sector work better for patients. It is an executive non-departmental public body, sponsored by the Department of Health. They rate NHS Foundation Trusts on their past, present and future performance [2]. They also provide real-time updates on the current status of Trusts’ performance. Monitor, along with NHSEngland and the NHS Trust Development Authority publishes annual planning guidance for foundation trusts (Monitor et al 2014). There is a section in this guidance entitled ‘Harnessing the information revolution and transparency’ (pp.19-20). The new National Information Board (NIB) brings national health and care organisations together with clinical leaders, local government and civil society. It has recently published Personalised Health and Care 2020: a Framework for Action which builds on commitments in the Forward View to use data and technology more effectively to transform outcomes for patients and citizens. It proposes six areas for action which refer to the disclosure of personal but not organisational information. 2. Key Findings and Analysis 2.1. Publication, Disclosure and Transparency The survey analysed and evaluated the information shared by Trusts in the FoI publication scheme, how FoI requests were disclosed to the public and the degree of transparency demonstrated. 2.1.1. Availability of a Publication Scheme The adoption and maintenance of a publication scheme (information regularly published by the organisation) is a requirement of the FoI Act (2000). The Information Commissioner’s Office publishes guidance on the scheme by providing a model available for download on its website (ICO 2013). The ICO provides clear guidance on how to comply with the publication scheme:

‘You should adopt the scheme and you need not tell the ICO you have done so. The model scheme is appropriate for all public authorities so you should not change it. You should also make sure you publish the information it covers. You should also produce:


a guide to information, specifying what information you publish and how it is available, for example, online or by contacting you; and

a schedule of fees, saying what you charge for information. You should publicise the fact that information is available to the public under the scheme. You should make sure the model scheme, guide to information, and schedule of fees are all available on your website, public notice board, or in any other way you normally communicate with the public.’

Of the 146 Trusts evaluated, 81% had made their publication scheme accessible on line either as web pages or PDF files. However, a significant 19% had not met this minimum legal requirement (Figure 1).

Figure 1: Availability of Publication Scheme (N)

The quality of the information provided varied with some only providing basic details of all information available while others made sections of their publications available through an accessible webpage. Central and North West London NHS Foundation Trust, for example, provided an example of good practice. They divided the scheme into sections with clickable access to documentation in each section as seen in the screenshot below (Figure 2).

Figure 2: Screenshot of Central and North West London NHS Foundation Trust Publication Scheme

Yes 118

No 28


2.1.2. Availability of a Disclosure Log A disclosure log is a mechanism for sharing responses to FoI requests. Of the Trusts under examination, less than a quarter (22%) had made disclosures available on line with the majority (78%) not making any attempt to share information in this way (Figure 3).

Figure 3: Availability of Disclosure Log (N)

Dudley Group NHS Foundation Trust provided an example of good practice by making all its disclosures accessible through a clickable webpage (Figure 2).

Figure 4: Screenshot of Dudley Group NHS Foundation Trust Disclosure Log 2.1.3. On-line transparency Where Trusts were providing accessible publication schemes and disclosure logs, they were considered as moving towards transparency as defined by Schnackenberg & Tomlinson (2014):

‘the perceived quality of intentionally shared information from a sender’ In this case, Trusts, acting as senders of information, had intentionally shared information and the quality of this information is perceived as acceptable and accessible by the receiver. A quarter of Trusts (20%) were considered transparent by this criteria (Figure 5).

Yes 32

No 114


Figure 5: Evidence of Transparency (N)

2.2. Responses to Freedom of Information (FoI)requests A request for information was made, by email, to the officer responsible for co-ordinating FoI requests in each Trust. The question asked was as follows: ‘Please could you provide a list of all service contracts awarded for what and to whom during 2013/2014 including maintenance, domestic, clinical, administrative, medical, care, consultancy and any other services?’ Requests were made to 146 Trusts. 60% replied within the 20 day period while 40% either did not reply within the 20 day period or failed to reply (Figure 6).

Figure 6: Responses to FoI Requests (N)

2.2.3. Classifying Responses to the Request Responses to the request were classified, in 4 categories, as follows: 1. Unable to process: too expensive to retrieve the required information Trusts that used Section 12 of the FoI Act to refuse providing the requested information on grounds of cost were exemplified by this response from Durham and Darlington NHS Foundation Trust:

‘The Trust does not centrally record this information. In order to collate this information someone would need to manually trawl through thousands of records. We are therefore refusing your request for information pursuant to section 12 of the Act on the grounds that we estimate that the cost of complying with the request would exceed the appropriate limit. The appropriate limit at the present time is £450.00 which equates to eighteen and a quarter hours of work by a member of staff at the rate of £25 per hour.’

This response implies that the information requested is held in a non-digital format which begs the question as to how the Trust monitors and evaluates expenditure if central digital records are not held of

Yes 29

No 117

Yes 87

No 59


levels of expenditure in any financial year. While it is acknowledged that some Trusts are relatively newly-formed, the initial step, in combining existing organisations would, normally be to collate levels and patterns of expenditure. 2. Unable to process: information required not available or held only within departments and not held centrally With some Trusts that offered the above response, it was unclear if the information was held in incompatible hard or soft copy formats: possibly in a combination of both. Where Trusts were an amalgamation of a number of Hospitals the issue of differing departments creating and storing information differently is clearly a problematic area. However, Trusts that responded appropriately and effectively often had invested considerable sums of money in installing new computer networks. 3. Processed: request only partially satisfied In some cases, Trusts failed to respond fully to the request, for example, by not providing information for the complete financial year or not covering all services. Others failed to provide details of the contract awarded or the contractor. Partial responses were queried but not always responded to appropriately or, in some cases, not responded to at all. Withholding the details of some contracts was considered, by some Trusts, to be in breach of confidentiality. However, no request was actually made for negotiated details of individual contracts, so, any rules or regulations of confidentiality do not apply. 4. Processed: request satisfied and further information provided Approximately 50% of Trusts responded in full to the request and within the 20 day period allowed by the FoI Act. Responses were received in various formats: Word, Excel and PDF. Most, but not all, information was tabulated in these formats. The most useful format is in Excel which allows further detailed analysis in chart and graphic representations. A minority of Trusts responded by offering extra information in the form of contract number, date awarded and started. Some published directly to their online disclosure log and provided the URL for the disclosure. Detailed responses which included further information tended to be provided by FoI teams that were led by the legal or financial team. 2.2.4. Trust Administration of FoI Requests There is considerable variation, between Trusts, on the managerial level at which FoI requests were handled. In some cases, requests were handled by the financial or legal team and, in others, by the administrative assistant to the Trust. The level of authority of the FoI officer could have considerable bearing on how requests are handled internally: a request from a solicitor having greater authority than that of an administrative assistant. The question of how FoI offices were staffed and the level of responsibility of officers was raised directly with the Information Commissioner’s Office which stated that they offered no advice on appropriate staffing of FoI offices within organisations. The ICO responded to a query on this, as follows:

‘We do not produce guidance in respect of how a public authority should structure itself so as to be able to comply with its obligations under the Freedom of Information Act. This is, in the first instance, a matter for the public authority.’


2.3. Monitor Governance and Continuity of Services Performance Criteria 2.3.1. Governance The governance rating is Monitor’s degree of concern about how the trust is run, any steps that are being taken to investigate this and any other action. The role of these ratings is to indicate when there is a cause for concern at a trust. A rating of green represents an acceptable level of governance while a red rating precedes the establishment of a review of systems. 70% of Trusts were rated as green, 11% red with 19% under review (Figure 7).

Figure 7: Governance Rating (N)

There appears to be no correlation [3] between the governance rating and the response to FoI requests. 2.3.2. Continuity of Services The continuity of services rating is Monitor’s view of the risk that the trust will fail to carry on as a going concern. A rating of 1 indicates the most serious risk and 4 the least risk. A rating of 2* means the trust has a risk rating of 2 but its financial position is unlikely to get worse. Only one Trust is currently rated 2*: University Hospitals Birmingham NHS Foundation Trust. 11% of Trusts were rated at level 1 and 11% were also considered to be level 2. 29% were rated at level 3; 49% at level 4 (Figure 8).

Figure 8: Continuity of Services Rating (N)

Similar to the governance rating, there appears to be no correlation between the continuity of services rating and the response to FoI requests. 2.3.3. Governance and Continuity of Services: Information Sharing In the interests of transparency, Trusts should be sharing the Monitor rating of governance ad continuity of services on their websites along with an explanation of their current status and any action proposed on reviewing or adjusting the status. In terms of good practice, this would be best provided on the homepage.

Green 102

Red 16

Review 28

1 16

2 16

3 42

4 72


3. Summary and Conclusion The transparency of 146 NHS Trusts in sharing information on the organisation in terms of the perceived quality of intentionally shared information from a sender (Schnackenberg & Tomlinson) has been surveyed, analysed and evaluated. An examination of online transparency revealed that a number of Trusts appeared to be failing to meet the requirements of the FoI Act (2000) by not providing a publication scheme. Some Trusts provided online access to a disclosure log of FoI requests. A relatively small number of Trusts could be considered as transparent in their attempts to share organisational information. Responses to the FoI request were varied in their nature and they varied in formats where information was provided. Where there was a failure to provide information, reasons given for inability to meet the request was questionable in some cases. The administration of FoI requests is an area of concern. There is considerable variation, between Trusts, on the managerial level at which FoI requests were handled. Trusts are not making Monitor’s ratings on Trust governance and services visible on their websites. In the interests of organisational transparency, all Trusts should:

publish their Publication Scheme online;

provide online access to a Disclosure Log which details responses to FoI requests;

provide responses to FoI requests, where appropriate, in a format readily available for further analysis, for example, in an Excel spreadsheet;

review how they respond to FoI requests and the level of responsibility within the organisation at which this is undertaken;

publish, on their homepage, the current Monitor rating for governance and continuity of services and an explanation of the assessment.


NOTES 1. The closest to a definition of transparency provided by NHSEngland is on the webpage: http://www.england.nhs.uk/tag/transparency/ which provides a series of quotations on the relevance of this term to service delivery. A definition of transparency, in terms of organisational information sharing is not provided. 2. Monitor publishes 2 ratings for each NHS Foundation Trust: i. The continuity of services rating is Monitor’s view of the risk that the trust will fail to carry on as a going concern. A rating of 1 indicates the most serious risk and 4 the least risk. A rating of 2* means the trust has a risk rating of 2 but its financial position is unlikely to get worse. ii. The governance rating is Monitor’s degree of concern about how the trust is run, any steps that are being taken to investigate this and any other action. The role of these ratings is to indicate when there is a cause for concern at a trust. The ratings do not automatically trigger regulatory action. They prompt Monitor to consider whether a more detailed investigation is needed. Monitor updates foundation trusts’ ratings each quarter and also in ‘real time’ to reflect any regulatory action taken. 3. In statistical analysis, correlation refers to the degree to which two or more attributes or measurements on the same group of elements show a tendency to vary together. So, in this case, the level of governance or continuity of services would be related to the provision of information if a correlation of 0 to +1 is evident. No such correlation was evident.


References ICO (2013) Model Publication Scheme Available from: https://ico.org.uk/for-organisations/guide-to-freedom-of-information/publication-scheme/ Monitor, NHSEngland and NHS Trust Development Authority (2014) Annual planning review 2015/16: guidance for foundation trusts Available at: https://www.gov.uk/government/publications/annual-planning-review-201516-guidance-for-foundation-trusts Schnackenberg, A. &Tomlinson, E., (2014) Organizational Transparency: A New Perspective on Managing Trust in Organization-Stakeholder Relationships Journal of Management DOI: 10.1177/0149206314525202. Available at: http://jom.sagepub.com/content/early/recent

https://ico.org.uk/for-organisations/guide-to-freedom-of-information/publication-scheme/

https://ico.org.uk/for-organisations/guide-to-freedom-of-information/publication-scheme/

https://www.gov.uk/government/publications/annual-planning-review-201516-guidance-for-foundation-trusts

https://www.gov.uk/government/publications/annual-planning-review-201516-guidance-for-foundation-trusts

http://jom.sagepub.com/content/early/recent

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