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Health Policy 111 (2014) 301–310

Contents lists available at ScienceDirect

Health Policy

journa l homepage: www.e lsev ier .com/ locate /hea l thpol

mpowerment or rhetoric? Investigating the role of NHSoundation Trust governors in the governance of patientafety�

osephine Oclooa,∗, Ali O’Sheab, Naomi Fulopc

The King’s Fund, Policy Department, 11-13 Cavendish Square, London, W1G 0AN, UKO’Shea Social Research, SW London, UKUniversity College London, Department of Applied Health Research, 1-19 Torrington Place, London, WC1E 7HT, UK

a r t i c l e i n f o

rticle history:eceived 26 July 2012eceived in revised form 29 April 2013ccepted 13 May 2013

eywords:ecision makingovernanceatient safetyser involvement

a b s t r a c t

Objectives: Involving patients and the public in patient safety is seen as central to healthreform internationally. In England, NHS Foundation Trusts are seen as one way to achieveinclusive governance by involving local communities. We analysed these arrangements bystudying lay governor involvement in the formal governance structures to improve patientsafety.Methods: Interviews with key informants, observations of meetings and documentary anal-ysis were conducted at a case study site. A national survey was conducted with all acuteFoundation Trusts (n = 90), with a response rate of 40% (n = 36). Follow up telephone inter-views were conducted with seven of these.Results: The case-study revealed a complex governance context for patient safety involvingboard, safety and various sub-committees. Governors were mainly not involved in theseformal mechanisms, with participation being seen to pose a conflict of interest with thegovernors’ role. Findings from the survey showed some involvement of governors in thegovernance of patient safety.

Conclusions: This study revealed a lack of inclusivity by Foundation Trusts of lay governors inpatient safety governance. It suggests action is needed to empower governors to undertaketheir statutory duties more effectively and particularly through clarification of their roleand the provision of targeted training and support to facilitate their involvement in the

ent safe2014 T

governance of pati©

. Introduction

The aim to develop greater patient and public involve-

ent (PPI) in shaping the organisation and delivery of

ealthcare has become central to health reform in Eng-and [1–5] and across the developed world [6,7]. Within

� This is an open-access article distributed under the terms of thereative Commons Attribution License, which permits unrestricted use,istribution and reproduction in any medium, provided the originaluthor and source are credited.∗ Corresponding author. Tel.: +44 020 73072678.

E-mail address: j.ocloo@kingsfund.org.uk (J. Ocloo).

168-8510/$ – see front matter © 2014 The Authors. Published by Elsevier Irelanttp://dx.doi.org/10.1016/j.healthpol.2013.05.005

ty.he Authors. Published by Elsevier Ireland Ltd. All rights reserved.

the English NHS the PPI agenda has been given greatermomentum by evidence of serious clinical and servicefailings in health [8–12]. These have frequently beenexposed by harmed patients and their families and havebeen highlighted most recently by the high profile FrancisInquiry [13] into one of the biggest patient safety failingsin the history of the NHS. A patient safety movementhas now emerged worldwide that incorporates demands,particularly by harmed patients, to be included in devel-

oping solutions to patient safety problems [14–16]. Akey emphasis driving policy developments has been tostress the benefits of participation as an important way ofimproving performance and quality [17,18] and achieving

d Ltd. All rights reserved.

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302 J. Ocloo et al. / Health

accountability from healthcare services and regulatorybodies [19,20]. Despite these drivers, there is evidencethat the role of patients and the public such as FoundationTrust (FT) lay governors, needs to be strengthened indecision-making [21–26].

PPI in health care is part of a wider movement involvingthe public in the management of public sector organisa-tions. Lay participation in school governance, for example,has been an important part of devolving management ofschools in England, as well as a number of other countries.This process has aimed to drive up standards, whilst alsobeing loosely linked to ideas about the accountability ofpublic service provision to the communities that use them[27]. However, research on governing bodies in schoolssuggests the role of governors needs to be strengthened(Farrell [22]), and it has been argued that shifting powerfrom professionals to citizens is essential in moving froma professionally dominated approach to one of citizen gov-ernance [28,29].

In relation to health care, Foundation Trusts (FTs) inEngland, established under the Health and Social Care(Community Health and Standards) Act [30], have beenseen as one way to achieve more inclusive governanceand citizen participation for local communities [31,32]. FTshave greater freedom than other NHS Trusts to managetheir affairs. Whilst they must continue to meet the samestandards and targets as other Trusts, they are not sub-ject to powers of direction by the Secretary of State andhave a separate regulator, Monitor [33]. FTs have a dutyto consult and engage with an elected board of governors(BoGs), (now called Council of Governors under the Healthand Social Care Act 2012), made up of patients, staff, mem-bers of the public and other key stakeholders. Governors inturn are held to account by the voting members recruitedto the Trust (patients, carers, staff and members of localcommunities), who are also able to stand for elections tothe governing board [31,34].

More generally, requirements to involve patients intheir individual care and treatment and in service planningand improvement have been reflected in legislation (NHSAct 2006) and registration requirements [35] and essentialstandards for quality and safety for all NHS Trusts [36]. Inpractice, however, there is little evidence that PPI is a main-stream activity that operates alongside other policy andperformance requirements in the NHS [3,37,38]. In patientsafety, evidence suggests that achieving PPI has been evenmore difficult [39–41], despite ample research illustratingpatients and the public can be involved in many differ-ent ways at both an individual patient level and in serviceplanning and provision [39,41].

This context raises questions about how patients andthe public can be empowered in PPI processes. McLean[42] has pointed to a consumerist model of empower-ment defined by service providers and policy makers ashaving ‘a narrow individualised focus on people’s abilityto make choices within predetermined service systems’[42,43, p. 277]. In contrast, a liberational model of empow-

erment: ‘implies that processes of social and civic life shouldbe designed to support and enable the participation of thosewho have previously been excluded from them. This meansthat change has to take place within social systems as well

11 (2014) 301–310

as within individuals and within services’ [43, p. 277, 44,p. 71]. In practice a number of factors have been iden-tified within health care systems and at an individuallevel that can hinder involvement in service planningand decision-making which include: lay people feelingunclear about their role and what is expected of them,a shortage of resources, concerns about representation[41] and resistance from healthcare staff and managers[41,45].

There is limited research on how to develop PPIspecifically in patient safety committees and governancestructures, although the principle of lay participation inclinical governance and at board level has long beenreinforced at a national policy level [23,46–49] and inter-nationally [14,16]. In developing PPI in patient safetygovernance further, however, adopting a more equal part-nership between professionals and patients has been seenas fundamental [23, p. 197], as well as helping to buildtrusting relationships which foster successful collaboration[50].

Research on FT governors suggests their role needs tobe strengthened if they are to be effective. There is a needfor improved operation of BoGs, better interaction withboards of directors (BoDs), and a need to provide furtherguidance to governors on understanding and discharg-ing their statutory duties [25,51]. There is a knowledge,skills and ‘experience gap’ with governors and ambigu-ity over governors’ roles and rights [24,52] and not allgovernors are able to hold their FT to account [21]. Allenet al. [26] found that the extent to which FTs provide waysfor public and patients to become involved in decisionsabout health care delivery is ‘variable and limited’ [26, p.252].

Current research on FT governors does not address thearea of patient safety. This needs to be addressed given FTsoperate governance arrangements that encourage a par-ticular form of PPI, in theory giving local stakeholders theopportunity to be involved in their strategic governance.Wright et al. argue that this position within a FTs internaladministrative structure means that governors constitute‘an ideal mechanism for installing deliberative values andpublic interest goals within the management culture ofacute hospitals’ [53, p. 6]. In the NHS, the operation ofTrust Boards of Directors has been found to be related toissues such as performance and organisational culture [54].International research confirms that not only is quality andsafety central to healthcare organisations, but that it is cru-cial for Boards to receive the appropriate support [54,55].This raises questions about the responsibility of BoGs andwhether they will be able to have any impact in the gov-ernance of quality and patient safety in FTs if they do nothave the skills, knowledge and powers to be effective inthese areas.

This paper addresses the issue of the role of FT pub-lic and patient governors in the governance of patientsafety, raising questions about the need for an empow-erment approach. It presents findings from a study of lay

governor involvement in the formal governance structureswithin acute NHS FTs relating to patient safety. The study’squestions were informed by current policy and literaturediscussed above: (1) to what extent are governors involved

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n the governance of patient safety and quality? (2) Whatactors facilitate and hinder the process of involvement?he paper suggests some ways in which governor involve-ent and PPI more generally, could be strengthened in the

mportant area of patient safety governance.

. Methods

The study used a mixed-method approach in order toroaden the evidence base and triangulate the data [56]nd was conducted in two phases: (i) a single case study ofFT undertaken between September 2008 and June 2009,f governor involvement in patient safety; (ii) a nationalurvey and follow-up interviews between May 2010 anday 2011, of PPI in patient safety in NHS Trusts. Findings

rom the FT case study mapping exercise helped inform sur-ey questions aimed at FTs around governor involvement.etailed information was drawn upon about FT gover-ance structures and the duties to involve governors, asell as how governors could more specifically be involved

n patient safety governance and how this differed fromPI more generally. FT survey and interview data in turnacilitated broader understanding of the case study data.nterviews were professionally transcribed. Researchersook detailed handwritten notes of committee meetings.ata were stored on a secure site to ensure confidentialityt all times.

.1. Single case study of a Foundation Trust

The strength of the case study method is its ability toxamine, in-depth, a “case” within its “real-life” context57]. Our case study provides a concrete example of whatatient safety involves and how it is operationalised inlarge, urban acute FT teaching hospital in England. A

mapping exercise’ was undertaken to document governornvolvement in the governance of patient safety. Multipleualitative methods were used which included carrying outbservations of the Safety and Patient Experience GroupSPEG) meetings (n = 7); two face-to-face interviews andne telephone interview with three senior managers; andwo meetings with three senior managers. Data were alsoollected from: (a) the Trust’s website on the governancetructure of the Trust, the BoDs, the BoGs, Trust mem-ership and the governors’ SPEG; (b) a Trust databasef key internal policy documents related to governance,afety and quality which included the Trust’s Risk Manage-ent Strategy and Governance Framework; (c) a second

atabase of activities on PPI and governor involvement inafety and quality activities such as infection control; (d)Trust employee on the role and terms of reference of

oard committees, the Quality and Safety Group (QSG) andhere they existed, terms of reference of various safety

elated sub-committees and the SPEG; (e) a search of wideriterature connected to the role of governors in FTs.

The mapping was completed by: (a) identifying a ‘corpo-ate map’ of the governance context of the Trust, excluding

ommittees that did not relate to safety and quality anddding committees that did; (b) using data identified to setut reporting lines between committees and (c) identifyingPI in these committees.

11 (2014) 301–310 303

2.2. National survey of PPI in patient safety in NHS Trusts

The survey findings presented in this paper are based onthe responses from acute FTs, gathered as part of a widernational online survey with 395 NHS Trusts on PPI gen-erally in patient safety activities. The whole population ofacute FTs (n = 90) was targeted through the NHS Confed-eration and NHS Choices database (May–October 2010).The response rate was 40% (n = 36). Seven of the respond-ing FTs participated in follow-up telephone interviewswhich generated a deeper understanding of key issues fromthe survey on governor involvement in the governanceof patient safety. Follow-up interviewees mainly occupiedleading roles in PPI or patient safety and had indicated onthe survey that they would be willing to participate in afollow-up interview (see examples of survey and interviewquestions in Appendix A).

3. Data analysis

The analysis of the qualitative data used a ‘Framework’approach [58], which provides a systematic way of classify-ing and analysing qualitative data, drawing upon deductiveand inductive approaches. Findings from the study devel-oped iteratively and were initially categorised under broadheadings and refined several times as the dataset was re-examined and new headings and subheadings emerged.

Mapping data from the case study were initially ana-lysed (by JO and CB) deductively to address the researchquestions. Data were then analysed inductively to look atkey committee structures identified by the Trust as respon-sible for monitoring patient safety and quality; how thesereported into strategic governance; level of lay involve-ment; key committee structures for governors in lookingat patient safety and quality, whether these were part ofthe formal governance context for monitoring safety andquality; and reasons given by the Trust for involving ornot involving governors in patient safety governance. Fol-lowing initial analysis of the mapping data, findings werediscussed with a broader group to achieve validity andfeedback enabled further refinement. This comprised thePatient Safety and Service Quality (PSSQ) research group,the Trust’s risk manager and a Research Action Group (RAG)including governors, members and senior trust manage-ment who helped to guide the research process.

Interview transcripts from the case study and surveydata were dual coded and analysed (by JO and AO) withthe assistance of Nvivo. Transcripts were initially readindependently and then discussed. Again analysis was car-ried out deductively in line with interview questions, theninductively looking at broader themes generated by thedata. During data collection and analysis, researchers corre-sponded with Monitor, the NHS FT regulatory body, to gainclarification on the policy and practice concerning governorinvolvement in the governance of patient safety.

Survey data were analysed using SPSS to identify typesand levels of governor involvement in formal gover-nance structures within the 36 responding FTs. Governorinvolvement was also categorised according to levels of

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participation in patient safety committees and types andamount of patient safety information received.

4. Results

4.1. Case study

Fig. 1 illustrates a wide-ranging and complex gover-nance context for managing patient safety and quality atthe case-study site at June 2009.

5. The governance context for patient safety

The bottom level (to the left) of Fig. 1 shows 11Risk/Governance Divisional committees (corresponding to8 Divisions at Trust level) and (to the right of the figure)22 Risk/Governance Sub-groups. These reported twice ayear, at 6 monthly intervals, into a central Quality andSafety Group (QSG), which met monthly. Many of thesecommittees had more specialist group meetings on variousareas such as mortality and morbidity, and the Sub-groupsattached to the committees also had a number of smallerSub-sub-groups. The QSG reported to three main Boardcommittees linked to patient safety, the Audit, Governanceand Performance committees, which reported to the Boardof Directors.

6. Patient and public involvement in thegovernance of patient safety

Fig. 1 shows that governor involvement in this processwas located in the Safety and Patient Experience Group(SPEG), an expert reference group of the Board of Gov-ernors. One governor also sat on the Food and NutritionSub-Group. Observations of the SPEG showed this com-mittee tended to concentrate more on patient experiencethan patient safety. The SPEG was located outside themain governance structure in the figure and did not reportdirectly into the QSC, although its work reported indirectlyto the QSC via the Patient and Carer Experience Group, asub-group of the QSC. Governors therefore tended not toparticipate in the formal governance context for patientsafety and quality shown in the figure.

Observations of SPEG meetings also indicated that gov-ernors had requested and been refused patient safetyinformation (e.g. data on serious untoward incidents (SUIs),patient safety incidents (PSIs), complaints and claims).Governors questioned “the extent to which SPEG can fulfilits obligations with regards to safety with and without accessto certain confidential Trust reports” (Researcher’s notes).Outside this formal structure, governors were involved invarious quality related initiatives and given all public per-formance and quality information presented to the BoDs.This included data on safety indicators including readmis-sion and standardised mortality rates, compliance with keytargets including cancer targets, health and safety informa-

tion (e.g. blood borne virus reported incidents), infectioncontrol data, complaints annual report and national andlocal patient survey results on environment, cleanliness,care perceptions and patient engagement. Governors did

11 (2014) 301–310

not receive clinical governance and risk managementreports which went to closed BoD meetings.

A number of explanations emerged for this lack ofinvolvement from the case study interviews. The BoDsand the BoGs were seen as having quite different roles.The BoDs’ role was defined as being strategic and opera-tional, with responsibility and accountability for ensuringthe Trust complied with its Terms of Authorisation andstatutory obligations. As well as their statutory roles, theBoGs had an important advisory role and held the BoDsto account. When asked initially about governor involve-ment in the governance of patient safety, a senior managercommented: ‘there is a difficulty about avoiding blurringthe lines of accountability [between BoDs and BoGs] and ofcourse the sensitivity and confidentiality issue and whetherstaff members of committees would then feel free to have anopen discussion’.

These concerns about the appropriate role of gover-nors in patient safety governance were explained in moredetail by three senior managers. One pointed out that thisarea reflected ‘very serious tensions and conflicts betweenthe Board and governors’ views on access to committees andinformation’. Given this resistance at a senior level, themanager considered ‘there was no point pushing against aclosed door’ in terms of discussions about greater governorinvolvement. Other concerns raised were that: ‘the gover-nor role was different to the general role of PPI’ and that itwas ‘more important for governors to retain their indepen-dence which could be compromised by involvement on boardcommittees’. Compromises to governors’ independence wasfelt to be a realistic outcome of governors sharing confiden-tial information from strategic committees more broadlywith fellow governors, thereby turning these issues intogovernance matters.

Governor involvement in strategic safety committeeswas also seen to present a potential conflict of interestin preventing Trust non-executive directors from carryingout their role in strategic committees because governorshad a role in holding non-executives to account. This con-cern extended to staff on committees who might find itdifficult to have open discussion if governors were presentat meetings: ‘non-executive directors are held to account bygovernors for their performance in these committees. If theyare there and they are working in the same way as the nursethen you have a problem about whether the nurse can do theirrole and also at the same time be accountable’ (non-executivedirector).

Further concerns questioned the appropriateness ofgovernor involvement in discussions of sensitive and con-fidential information about staff and patients: ‘safety isalso an issue where we are talking about individuals, right,because you can have personal identifiers which would meanthat they would know who the patient is or who the mem-ber of staff is that we’re dealing with on those issues’(non-executive director). These concerns extended to com-mercial, human resources and management information.However, whilst there was clearly strong resistance to gov-

ernor involvement in patient safety governance amongstthe interviewees, one manager stated that they ‘would haveno objection to say two lay people or governors on any of thecommittees, but they would have to be knowledgeable, and

J. Ocloo et al. / Health Policy 111 (2014) 301–310 305

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below shows that the majority of responding FTs gave allcategories of patient safety information to governors.

Table 1Levels of governor involvement in patient safety committees.

Levels of governor involvement in 3 types ofpatient safety committee (board sub-committees,main patient safety/clinical governance andcomplaints committees)

Number oftrusts(n = 33)

Fig. 1. Governance structure of pa

hey would be over a period of time. They would have to behaveesponsibly, and they would have to agree with confidential-ty where appropriate’. This manager was not prepared tonvolve patients who ‘have personally been harmed by thisospital, I would not put you on that committee. . .. . .. . . Iorry about public representation on things like that. Youave to be representative, you have to be fair’.

In light of these findings, guidance was sought fromonitor (March 2009; November 2011) on whether gov-

rnor involvement in patient safety governance couldresent a conflict of interest. Monitor did not consider it toe a conflict of interest, except where information involvedrivacy or data protection issues relating to patient/staffonfidentiality, in terms of access to names of individuals.

.1. National survey of PPI in patient safety

Findings from survey and interview data showed somenvolvement of governors in the governance of patientafety. Thirty three out of 36 responding FTs answeredhe question on governor involvement as members of highevel patient safety committees. Governor involvement

as reported on just under a half of board sub-committees

n = 16; 48%) and main patient safety/clinical governanceommittees (n = 14; 42%); and just under a third of com-laints committees (n = 10; 30%). Table 1 below shows

evels of governor involvement across responding FTs and

fety and quality at case study site.

highlights that in 20 out of the 33 Trusts, governors areinvolved in only one or none of the committees.

At the time of conducting the case study mappingexercise, findings indicated that the Trust did not involvegovernors in any of the three patient safety committees inTable 1 above.

Thirty out of 36 FTs responded to the question on giv-ing patient safety information to governors. All 30 FTsreported giving information to governors on complaints.The majority of FTs reported giving information relating tothe following five categories: PSIs (n = 28, 93%); SUIs (n = 27,90%) and PALS data (n = 25, 83%) and less information wasgiven on clinical negligent claims (n = 20, 67%). Table 2

No involvement 10Low involvement (1 committee) 10Moderate involvement (2 committees) 8High involvement (all 3 committees) 5

306 J. Ocloo et al. / Health Policy 1

Table 2Levels of patient safety information given to governors.

Patient safety information given to governorsacross 5 categories (complaints, PSIs, SUIs, PALSand claims)

Number oftrusts (n = 30)

Gave little information (only 1 category) 0Gave some information (2–4 categories) 13Gave all information (5 categories) 17

Findings from the case study Trust showed that it did notgive the patient safety information mentioned in Table 2 togovernors, apart from complaints data in its annual report.

In follow-up interviews, four out of seven FTs providedsome examples of how and where governors were involvedin patient safety governance. One Trust had decided toinvolve governors extensively in all their governance com-mittees, but a senior consultant reported the Trust thenconsidered, ‘well hang on do you not realise what’s discussedin some of these things. It’s just not appropriate, we cannotdo this’. After reflection the interviewee pointed out: ‘we’vetaken a step back and we’re down to about 70% [governorinvolvement in strategic committees connected to gover-nance and safety], which I think is still a pretty good strikereally’. The interviewee believed the main barriers to thisprocess were addressing staff attitudes, which needed tocome from ‘across the whole of the Trust really’ and par-ticularly ‘to come from the top’. It was also important ‘todemonstrate that there is learning to be had’ from the pro-cess. To support governor involvement, the intervieweecommented, the Trust decided to institute the same typeof training as provided for non-executives. The Trust con-sidered that before governors ‘start to ask questions andthump on tables, it would be easier to explain in quite a lotof detail who we are, what we do, and how we work so thatyou can ask the right questions’. The interviewee added, ‘wealso put some big chunks in on patient safety and our safetyagenda’.

The remaining three FTs involved governors in differ-ent ways in various operational committees below Boardlevel, related to patient safety. One Trust involved gover-nors in several committees that looked at risk and patientsafety which were not sub-committees of the Board butsat below this and were considered ‘fairly high level, butquite operational’. However, whilst strategic patient safetyinformation was discussed in these meetings, the patientsafety manager implied that this did not all go directly tothe Council of Governors. The interviewee noted that therewas a section on the agenda of the Council of Governors forgovernors on committees to report back (although this wasclearly optional), ‘if they feel it’s necessary to report some-thing’. With another FT, the assistant director of nursingreported governor involvement in key operational groupssuch as the Infection Control Operational Group, NutritionSteering Group and End of Life Steering Group. The inter-viewee believed that involvement did ‘work quite well’, butnoted, ‘we’ve looked at providing them all with some train-ing [as] some of them are more confident and competent than

others given their different backgrounds and areas of expertiseand because we’re not sure they have all got the informationthey need’, given the complexity of the NHS. The last FTreported governor involvement on their Patient Safety and

11 (2014) 301–310

Quality Committee who then fed back to the wider Board ofGovernors. The interviewee felt that ‘really understandingthe safety issues from the patient’s point of view, a layper-son’s point of view’ was really important but also noted, ‘Ithink the layperson who sits on that group, or the [gover-nor] observer, doesn’t participate actively but the non-execas the chair of that group has brought a much greater sort offocus’.

Key issues to emerge from the other three FTs thatdid not have governor involvement in committees relatedto: a need for clarity about the involvement opportuni-ties available for PPI in patient safety. One intervieweestated, ‘It’s not been something that’s been considered in thepast’. Another interviewee commented, ‘I think it dependshow you choose to use your governors and we’ve chosento use ours really as – market research sounds terrible butthat’s what they are, they’re our customer panel and sound-ing board’. Other issues were around the need to help laypeople develop their knowledge on patient safety and whatit means, and to provide support and training to be involvedin this area.

7. Discussion

Our findings indicate that there is some developingpractice of governor involvement in the governance ofpatient safety in some areas amongst FTs, for examplethe levels of patient safety information given to gover-nors according to survey data. However, they also revealeda lack of governor involvement in other patient safetyactivities within many FTs. For example, less than half ofresponding FTs in the survey had governor involvementin high level safety committees despite BoGs being a cen-tral part of their governance structures. At the case studyTrust, findings suggest governors were disempowered bythe existence of ambiguity and inherent tensions in thegovernors’ role, with governors not being given access byFT management to strategic patient safety information orseen as having a role in patient safety governance. Gov-ernors are therefore likely to require targeted training,support and guidance to gain the key skills, knowledge andexperience to be appropriately involved in the governanceof patient safety. Guidance for FTs should clarify in whatareas and levels of governance governors can be involved,what information they are entitled to, how any issues ofconfidentiality should be addressed, and how feedbackmechanisms should operate when governors are report-ing back from committees to Governing Boards and to thewider community.

The new Health and Social Care Act 2012 aims tostrengthen the duties of governors and gives Council ofGovernors (as BoGs will be called), important new dutieswith respect to ensuring the performance of NHS Trusts.Governors will have a duty to hold non-executive directors,individually and collectively, to account for the perfor-mance of the board of directors. They will also have a duty

to represent the interests of members of the Trust and thepublic as a whole. Despite these new powers, our findingssuggest that governors will not be able to fulfil their dutieseffectively in monitoring performance, including quality

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nd patient safety, if they are not empowered to be involvedn areas like the governance of patient safety.

Wright et al. [53] argue that the current way that FTsre constituted actively disempowers governors and there-ore fails to deliver local accountability. To strengthenhe role of governors in FTs, they call for policy mak-rs to reframe the role of governors as ‘meta-regulators’,art of a larger network of regulatory strategies for influ-ncing the management culture of FTs in the directionf compliance with wider social and government goals59]. These concerns have been reinforced by the Fran-is Report [13] which argues that not only does theole of FT governors need to be enhanced, improved andade accountable, published guidance should set out the

rinciples that governors should follow to ensure effec-ive public accountability. Whilst the report states thatccess to external assistance and support should be pro-ided by their national association, Wright et al. [53]rgue that a key requirement for strengthening the rolef governors is for national bodies such as the Depart-ent of Health, and regulatory agencies to take formal

esponsibility for the training and induction of governors,ather than FTs who currently hold this responsibility59].

In strengthening the duties of governors it will bemportant to establish whether governors have the righto be given all patient safety information, seen as anmportant part of the accountability arrangements ofHS Trusts [40]. Findings from our research suggest that

ome Trusts still have considerable reservations aboutiving patient safety information to lay members, whichs then likely to prevent them allowing involvement intrategic patient safety committees and decision-making.trategic patient safety information, however, has longeen made publicly available in non-FT Trusts as partf their duty to hold their Board meetings in public.herefore, providing that relevant information is madenonymous in order to protect staff and patients, it iseasonable to assume that the same principle may bepplied successfully in FTs by way of achieving greaterovernor involvement. In school governance, an impor-ant element of an empowerment approach is ensuringovernors have a range of information sources availableo them and not just that which is provided by profes-ionals [28, p. 36]. In tackling these issues in health caret will be important to address underlying staff concernsnd fears concerning potential litigation and blame [60].hese fears are likely to prevent the further involvementf patients and the public in the governance of patientafety, arguably, especially harmed patients and their fam-lies.

This paper draws from the findings of a nationalurvey and a single case study. The survey had aelatively low response rate. However, the seven follow-p interviews and the case study generated richata which enabled us to explore and understand inreater depth some of the challenges underlying the

ole of FT governors in the governance of patientafety.

11 (2014) 301–310 307

8. Conclusion

Under Government proposals, all NHS Trusts are tobecome FTs by 2014. Within this policy context these find-ings suggest that action is needed to empower governorsto be involved in patient safety governance though the pro-vision of clear guidance about their role, through increasedtraining and support and access to strategic patient safetyinformation. Governors may already have more knowl-edge about the governance of NHS Trusts than patients andthe public more generally. Therefore it is also likely thatpatients and the public will need even greater support to beinvolved in patient safety and in addressing performanceand accountability in healthcare in the future.

Funding

The research on the case study was undertaken at theNIHR King’s Patient Safety and Service Quality ResearchCentre (King’s PSSQRC), part of the National Institute forHealth Research (NIHR). The national survey was fundedby the Department of Health from 2010–2012. The viewsexpressed in this publication are those of the authors andnot necessarily those of the NHS, the NIHR, or the Depart-ment of Health.

Competing interests

None.

Ethical approval

The mapping exercise at the case study site receivedethical approval from King’s College London on 16thSeptember 2008 (REPSSPP(W)-0708-296). The nationalsurvey received an exemption from NHS ethical approval(22nd February 2010) and ethical approval King’s CollegeLondon (REP(EM)/09/10-47) on the 11th May 2010.

Acknowledgements

We would particularly like to thank the governors andstaff involved in the RAG for contributing to the research atthe case study site. We would also like to thank Carol Bell forassistance with the case study, and Madeleine Knight, CarinMagnusson, Rhiannon Walters, Christopher Woodrow andMartin Bulmer for their work on the national survey as wellas The NHS Confederation. Our thanks also go to colleaguesat King’s Patient Safety and Service Quality Research Centrefor their comments on earlier drafts of the paper.

Appendix A.

A.1. National NHS survey on PPE in patient safety –Foundation Trusts

complete. Your input is highly valuable and will enable usto develop and share good practice in this area.

Policy 111 (2014) 301–310

safety? (please tick all relevant boxes) �p PPE in patient safety �velop PPE in patient safety �y �gaged in patient safety activities �ty activities �

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308 J. Ocloo et al. / Health

(1) Has your Trust taken any specific action to develop PPE in patient(a) Discussed at the Board of Directors (in the last 2 years) how to develo(b) Discussed with the Board of Governors (in the last 2 years) how to de(c) Developed a strategy/policy document relating to PPE in patient safet(d) Discussed (with patients and public) whether they would like to be en(e) Discussed with relevant staff about how to develop PPE in patient safe(f) Identified specific patient safety activities where the engagement of p(g) Other (please describe)(h) None of the above

(2) Has the Trust taken any specific action to implement Recommenda(a) Discussed the recommendation at the Board of Directors (in the last 2(b) Discussed the recommendation with the Board of Governors (in the la(c) Developed a strategy/policy document relating to PPE in patient safet(d) Discussed (with patients and public) about whether they would like t(e) Discussed with relevant staff about how to develop PPE in patient safe(f) Identified specific patient safety activities where the engagement of p(g) Other (please describe)(h) None of the above

(3) Do you give patient safety information (such as the information inorganisation? Please tick the relevant categories of information below(a) Complaints(b) Patients Safety Incidents Data (PSI)(c) Serious Untoward Incidents Data (SUIs)(d) PALS Data(e) Clinical Negligence Claims(f) Key Performance Data (e.g. performance against national targets suchetc.)(g) Other (please describe)(h) None of the above

(3.1) Do you give patient safety information (such as the informationPlease tick the relevant categories of information below:(a) Complaints(b) Patients Safety Incidents Data (PSI)(c) Serious Untoward Incidents Data (SUIs)(d) PALS Data(e) Clinical Negligence Claims(f) Key Performance Data (e.g. performance against national targets suchetc.)(g) Other (please describe)(h) None of the above

(3.2) How is this information above given out? (please tick all relevan(a) In Board Reports(b) Making available clinical governance reports(c) Putting information on Websites(d) Providing summaries of patient safety information(e) Through Patient Safety/Quality/Risk Committees(f) At the Board of Governors(g) At Board of Governor sub-committees(h) Other (please describe)(i) None of the above

(4) Are patients and the public engaged in any of the following activit(4.1) Engaged in Committees:(a) As a representative on the Board(b) As a representative on Board Sub-Committees that deal with patient s(c) As a representative on the main Patient Safety/Clinical Governance Cosafety at the trust(d) As a representative on Complaints Committees

Are Governors specifically engaged in any of the following committee(a) As a representative on the Board(b) As a representative on Board Sub-Committees that deal with patient s(c) As a representative on the main Patient Safety/Clinical Governance Cosafety at the trust(d) As a representative on Complaints Committees

(4.2) Providing feedback on patient safety policy (please tick which categorie(a) Leaflets(b) Patient safety reports/documents (e.g. being open policy)(c) Other (please give examples)

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4.3) Involvement in other patient safety activities (please tick whicha) PEAT (Patient Environment Action Team)b) Safety related ward roundsc) Root cause analysisd) PSI investigatione) Complaints handlingf) Infection control activitiesg) Use of patient stories at Board levelh) Use of patient stories in staff trainingi) Other (please describe)j) None of the above

5) Are you carrying out any specific work with those affected by patieo, go to Q6; If yes, are they engaged in:

a) Patient safety committees reporting into the Boardb) Other patient safety committeesc) Safety related ward roundsd) Incident investigatione) RCA analysisf) Complaints handlingg) PEAT (Patient Environment Action Team) visitsh) Infection control activitiesi) Use of patient story at Board levelj) Other (please describe)

6) Good practice examples (please give any examples of any activitiesn practice)

7) Support for PPE in patient safety: do you carry out any of the folloick all relevant boxes)?a) Training for patients and the publicb) Training for staffc) Payment of travel expenses for patients and publicd) Payment for reimbursement of time for patients and the public

7.1) What additional support do you think would be useful to develoa) For patients and the publicb) For staff

8) Are there any factors that you think prevent patient and public en

9) If you have any other comments you would like to make, which haescribe

he individual results of this survey will be kept confidential. If you arollowing box:

ollow up interviews: We are also looking for NHS Trusts which would brusts to share a range of experiences with us so that we can progress won these interviews we would like to discuss factors that facilitate or hindhat could be provided to patients and the public to support their engagef you would be willing to provide an interview please provide your conta

ame:

elephone number:

mail:

hank you for completing the survey

Questions used in interviews with Foundation Trusts:

(a) How and in what ways are NHS Trusts currentlyinvolving patients and the public in patient safety gov-ernance/activities.

(b) What factors facilitate or hinder the process of involve-ment?

(c) How do healthcare staff members relate to the involve-ment process in terms of support for or resistance to it

11 (2014) 301–310 309

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y to be contacted about your comments please tick the

g to participate in a follow-up interview. We are looking fors important area.rocess of PPE involvement, and methods and approachespatient safety activities?ls below.

and what assistance do they require to support involve-ment processes?

(d) What methods could be provided to patients and thepublic to support their engagement in patient safetyactivities?

References

[1] Department of Health. A stronger local voice: a framework for cre-ating a stronger local voice in the development of health and socialcare services; 2006. London.

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[2] Department of Health. World class commissioning; 2007. London.[3] Department of Health. Real involvement: working with people to

improve services; 2008. London.[4] Department of Health. The NHS constitution. London: DOH; 2010.[5] Department of Health. The NHS plan. London: The Stationery Office;

2000.[6] Church J, Saunders D, Wanke M, Pong R, Spooner C, Dorgan M.

Citizen participation in health decision-making: past experienceand future prospects. Journal of Public Health Policy 2002;23(1):12–32.

[7] Wait S, Nolte E. Public involvement policies in health: explor-ing their conceptual basis. Health Economics, Policy and Law2006;1(2):149–62.

[8] Royal Liverpool Children’s Inquiry. The Royal Liverpool Children’sInquiry report; 2001. London.

[9] Bristol Royal Infirmary Inquiry. The Report of the Public Inquiry intochildren’s heart surgery at the Bristol Royal Infirmary 1984–1995;2001. London.

10] Department of Health. The Shipman Inquiry fifth report. Safeguard-ing patients: lessons from the past—proposals for the future; 2005.London.

11] Healthcare Commission. Investigation into outbreaks of Clostridiumdifficile at Maidstone and Tunbridge Wells NHS Trust; 2008. London.

12] Mid Staffordshire NHS Foundation Trust Inquiry. Independentinquiry into care provided by Mid Staffordshire NHS FoundationTrust. London: The Stationery Office; 2010.

13] Francis R. Report of the Mid Staffordshire NHS Foundation Trust Pub-lic Inquiry; 2013. London.

14] WHO. European regional patients for patient safety workshop report;2007. Geneva.

15] Ocloo J. Towards partnership: patient and public involvement inpatient safety. Health Care Risk Report 2008;14(5):15–7.

16] Newell SM, Jones DA, Hatlie MJ. Partnership with patients to improvepatient safety. Medical Journal of Australia 2010;192(2):63–4.

17] Baggott R. A funny thing happened on the way to the forum? Reform-ing patient and public involvement in the NHS in England. PublicAdministration 2005;83(3):533–51.

18] Rutter D, Manley C, Weaver T, Crawford MJ, Fulop N. Patients or part-ners? Case studies of user involvement in the planning and deliveryof adult mental health services in London. Social Science & Medicine2004;58:1973–84.

19] Davies HTO, Shields AV. Public trust and accountability for clinicalperformance: lessons from the national press reportage of the Bristolhearing. Journal of Evaluation in Clinical Practice 1999;5(3):335–42.

20] Irvine D. The doctors’ tale. London: Routledge; 2004.21] Allen P, Keen J, Wright J, Dempster P, Townsend J, Hutchings A,

Street A, Verzulli R. Investigating the governance of autonomouspublic hospitals in England: multi-site case study of NHS foundationtrusts. Journal of Health Services Research and Policy 2012;17(2):94–100.

22] Farrell CM. Governance in the UK public sector: the involve-ment of the governing board. Public Administration 2005;83(1):89–110.

23] Pickard S, Marshall M, Rogers A, Sheaff R, Sibbald B, Campbell S, Hal-liwell S, Roland M. User involvement in clinical governance. HealthExpectations 2002;5(3):187–98.

24] Lewis R, Hinton L. Putting health in local hands: early experiences ofHomerton University Hospital NHS Foundation Trust; 2005. London.

25] Monitor. Developing the role of NHS foundation trust governors;2008. London.

26] Allen P, Townsend J, Dempster P, Wright J, Hutchings A, Keen J. Orga-nizational form as a mechanism to involve staff, public and users inpublic services: a study of the governance of NHS Foundation Trusts.Social Policy & Administration 2012;46(3):239–57.

27] Deem free marketeers or good citizens? Educational policy and layparticipation in the administration of schools. British Journal of Edu-

cational Studies 1994;42(1):23–37.

28] Farrell C. The public manager in 2010: citizen participation in gover-nance. Public Money and Management 2000;20(1):31–7.

29] Box R. Citizen governance, leading American communities into the21st century. Thousand Oaks: Sage; 1998.

[

[

11 (2014) 301–310

30] Health and Social Care (Community Health and Standards) Act; 2003.United Kingdom.

31] Department of Health. A short guide to NHS Foundation Trusts; 2005.London.

32] Dedeu T. Participation of the public in the governance of healthcareorganisations. Revista de Innovación Sanitaria y Atención Integrada(RISAI) 2010;2(1):1–7.

33] Dixon A, Storey J, Alvarez Rosete A. Accountability of foundationtrusts in the English NHS: views of directors and governors. Journalof Health Services Research and Policy 2010;15(2):82–9.

34] Maybin J, Addicott R, Dixon A, Storey J. Accountability in theNHS—implications of the government’s reform programme. London:King’s Fund; 2011.

35] Care Quality Commission. A new system of registration. London: CareQuality Commission; 2009.

36] Care Quality Commission. Essential standards of quality and safety,London. London: Care Quality Commission; 2010.

37] Healthcare Commission. Listening, learning, working together?;2009. London.

38] Parsons S, Winterbottom A, Cross P, Redding D. The quality of patientengagement and involvement in primary care; 2010. London.

39] Vincent CA, Coulter A. Patient safety: what about the patient? Qualityand Safety in Health Care 2002;11:76–80.

40] Colin-Thome D. Mid Staffordshire NHS Foundation Trust: a reviewof lessons learnt for commissioners and performance managers fol-lowing the Healthcare Commission investigation; 2009. London.

41] Coulter A, Ellins J. Patient-focused interventions: a review of theevidence. London: Picker Institute; 2006.

42] McLean A. Empowerment and the psychiatric consumer/ex-patientmovement in the United States: contradictions, crisis and change.Social Science and Medicine 1995;40(8):1053–71.

43] Starkey F. The professional and liberational perspectives in socialcare. Social Policy and Society 2003;2(4):273–84.

44] Barnes M. Families and empowerment. In: Ramcharan P, et al., edi-tors. Empowerment in everyday life: learning disability. London:Jessica Kingsley; 1997. p. 70–87.

45] Greenhalgh T, Humphrey C, Woodard F. User involvement in healthcare. Chichester: Blackwell Publishing Ltd.; 2011.

46] Department of Health. Safety first; 2006. London.47] National Health Service Executive. Clinical governance in the new

NHS. London: National Health Service Executive; 1999.48] National Leadership Council. The Health NHS Board—principles for

good governance; 2010. London.49] Department of Health. Tackling concerns locally—report of the clin-

ical governance sub-group. London: DOH; 2009.50] Fleming-Carroll B, Matlow A, Dooley S, McDonald V, Meighan K, Stre-

itenberger K. Patient safety in a pediatric centre: partnering withfamilies. Healthcare Quarterly 2006;9(special issue):96–101.

51] Monitor. Survey of Foundation Trust Governors; 2008. London.52] Lewis R. Governing Foundation Trusts—a new era for public account-

ability; 2003. London.53] Wright JSF, Dempster PG, Keen J, Allen P, Hutchings A. The new gov-

ernance arrangements for NHS foundation trust hospitals: reframinggovernors as meta-regulators. Public Administration 2011.

54] Ramsay A, Fulop N. The Healthy NHS Board: a review of guidance andresearch evidence; 2010. London.

55] Baker GR, Dennis J-L, Pomey P-M, Mackintosh-Murray A. Effectivegovernance for quality and patient safety in Canadian Healthcareorganizations: a report to the Canadian Health Services ResearchFoundation and the Canadian Patient Safety Institute; 2009. Ottawa.

56] Mason J. Qualitative researching, 2nd ed. London: SAGE Publications;2002.

57] Yin R. Case study methods; 2004.58] Ritchie J, Spencer L. Qualitative data analysis for applied policy

research. In: Bryman A, Burgess RG, editors. Analyzing qualitativedata. London: Routledge; 1994.

59] Wright JSF, et al. The new governance arrangements for NHS founda-tion trust hospitals: reframing governors as meta-regulators. PublicAdministration 2011;90(2):351–69.

60] Barnard C, Dvorak M, Hatlie M.The Chicago Patient Safety Workshop.2008.