Care Quality Commission Board meetings, 23 Sep 2015

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From YouTube: CQC Board Meeting 23 September 2015

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The Care Quality Commission's Board Meeting was held in London on 23 September 2015
Please scroll below to navigate the agenda items:

1 Values Based Organisation and Leadership 0:35
2 Apologies and Declarations of Interest 1:04:23
3 Minutes of the meeting held on 29 July 2015 1:04:55
4 Matters Arising and action log 1:04:55
5 Chief Executive's Report 1:05:55
6 Fit and Proper Person 1:42:42
7 Duty of Candour 1:42:42
8 A. Full report from Regulatory Governance Committee held on 28 July
B. Report from Regulatory Governance Committee meeting held 22 September 2:21:01
9 Questions 2:29:39
10 Any Other Business 2:45:07

Read more about CQC's Board Meetings at
http://www.cqc.org.uk/public/about-us/our-people/board-members/board-meetings

A

≫≫ Good morning, everybody.

A

I took I suppose the only decision I've taken as the acting chair,, which was.

A

That we should have our board meeting in the same place as the senior team are.

A

And also I thought having a board meeting with natural light sort of.

A

Surrounding us would be a good idea, compared to the rather subterranean.

A

Space we had before.

A

Now, we're very privileged this morning to have Andrew Foster and.

A

Umesh Prabhu with us because they have pulled off something,, I, think,.

A

Rather remarkable at their Trust.

A

And, so instead of having the minutes first and David's, report, I think we are.

A

Going to go straight in to the presentation and then a discussion about the Trust.

A

So again,, thank you so much for coming today.

A

I think all of us do recognise, and it is genuinely important for us to hear what.

A

You've got to say and how you managed to transform the Trust.

B

≫≫ Okay, well, thank you very much.. We both feel equally honoured to be here and looking forward to presenting.

B

Our story and then having some discussion with you.

B

Just by way of introduction,, you will see that there are no less than 53 slides.

B

Here, but I promise you we will go through them very rapidly,, mostly.

B

There will be one or two we'll linger on and because we are doing it, this way,.

B

I am going to say what slide number we are on, because this is being videoed at.

B

The same time,, you have got your hard copies, but it's to guide people through.

B

Essentially, this is a story about achieving a certain culture in an.

B

Organisation,, it's a story that goes in two halves,. The first half is about quality and.

B

The second half,, which is where Dr Prabhu comes in,, is about quality values.

B

Based leadership and staff engagement combined,, but it's an.

B

Unusual organisation in many ways, Wrightington,, Wigan and Leigh, and it's.

B

Developed a culture which is I think something very admirable.

B

And a first illustration of this came in a case in November last year,, when we.

B

Had a 77-year-old lady on the ward, who was dying.

B

She knew she was dying and the staff knew she was dying.

B

And. The nurses said to her one morning,. They asked if there was anything they could do for her and she said yes,. She would like to be able to say goodbye to Bronwyn.

B

But Bronwyn turned out to be a race horse.

B

Now, the nursing staff could have said, don't be silly,. We can't a get horse into a.

B

Hospital, but they didn't. They, thought about it very carefully and did a risk assessment and they.

B

Arranged,, you can see on slide two, they arranged to get the patient wheeled.

B

Down into the corridor to the hospital car park, where the family had brought the.

B

Horse in a horsebox and the two met.

B

And, you can see on slide three, one of the most extraordinary pictures in NHS history.

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It's extraordinary for two reasons,, when the horse saw the lady, it bent down and.

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Nuzzled, her face,, it kissed her and the other is this photograph,, which happens.

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To be a perfect photograph taken by a rank amateur,, but it's the perfect, tells.

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The whole story of going the extra mile, compassionate care,, the NHS at its best.

B

And through social media,, this went viral and was viewed by over 50 million.

B

People,, so it's not a bad way to start the story of Wigan, even though it comes.

B

Towards the end. Talking about the culture,, the journey on quality, so slides, four and five,, it's really.

B

About that journey, although the picture on slide, five is meant to have a beautiful.

B

Vision of the future, but when I presented it to the consultants committee,, it said it.

B

Just shows the management can't tell the woods from the trees.

B

Slide six is what WWL was like in 2006 and I am not being rude, particularly to.

B

Wwl, it's what the NHS was like when it came to quality initiatives.

B

Of course clinicians had quality, but they didn't have systematic quality,.

B

The idea of quality, improvement, and I was astonished to do the leaving.

B

Presentation for the nurse director and for the purposes of that, I got hold of her.

B

Job description from 2006, and can you imagine that there was a nurse.

B

Director's job description, which did not contain the word quality or safety as.

B

Recently, as 2006.

B

So, that was the starting point.

B

Quite rapidly, we developed a schematic,, the WWL Wheel,, which you can see on.

B

Page 7,, which I think should appeal particularly strongly to the CQC, because.

B

You can see that at the heart of it, it's got our patients and then it's got safe,.

B

Effective and caring as being the definition of quality.

B

Around, the outside of the wheel,, there are values, which were constructed in.

B

Consultation with our staff, and at the bottom is the board's corporate objectives.

B

So in one page, this summarises what we are trying to achieve and that's been.

B

The same for seven years now so there's a degree of consistency about what we.

B

Are trying to do.

B

On slide eight,? We have some very important statements which again I think.

B

Are very interesting and relevant to the CQC.

B

A lot of people think that NHS managers just care about money and targets, and.

B

Yes, we do care about money and targets, but in our Trust we constantly make the.

B

Statement that quality is level with those,, so you can't do one without the other;.

B

You have got to do all three and then safety, trumps, everything.

B

So, we constantly say to our staff,: do not meet a target if it's going to compromise.

B

Safety, do not save money if it's going to compromise safety.

B

Staff and patient safety beats absolutely everything.

B

And, what we want staff to do is to tell us not just when they see something.

B

Has gone wrong, but when they see something that might have gone wrong.

B

We are complete fans of the IHI and other bodies that are turning health care.

B

Improvement into a science. So, this isn't just fancy fluffy words about quality and so on,. This is hard nosed,.

B

Evidence based and above all, it's measured.

B

On on slide nine,, you can see the Trust journey on MRSA.

B

Probably similar to other Trusts, except we started this earlier, and one of the big.

B

Things I'd like to say is that we started this in 2007/8 and you can see that in.

B

That year,, the number of MRSAs came down from 39 to 19.

B

One of the big boosts that we got was that we got quick results early on which.

B

Began to establish credibility for our quality programme.

B

Slide 10 shows the same story: tor C Diff,, astonishing that we had as many.

B

As 370 cases a year of C Diff quite recently, and that represents one entire.

B

Ward of patients with C Diff.

B

So there's another important message here: that when you improve quality and.

B

Safety,, you can also reduce cost. So, that million or so pounds that we spent in those days dealing with C Diff.

B

Patients is now spent elsewhere.

B

The other big initiative we had was on mortality reduction and on slide 11,.

B

You will see our mortality picture.

B

This is not our graph,. This is from Dr. Foster and each of those diamonds.

B

Represents a year, and you can see that in 2007/8, we had a mortality ratio of 126.

B

That happens to be the same figure as Mid Staffs had for the same year.

B

Now,, that was the start of our journey and we were horrified by that and we.

B

Said right, we want to adopt IHI improvement techniques and start.

B

Tackling excess mortality and we did get a bit of grumbling to start with that. The.

B

Figures were probably rubbish, but we said never mind that,. We just want to improve.

B

Again you can see in just the first year,. There was a dramatic improvement in.

B

Mortality and HSMR is a bit of a statistical construct.

B

If you go to slide 12,, you can see the actual number of,. Just the crude.

B

Numbers of deaths in hospital. And. This shows you that in the year before we started, there were just under 1,600 deaths, and in the latest year here, it's about 1,150.

B

Now, what can account for reduction of 450 deaths? A year?.

B

Well,, there's no increase in the proportion of people dying at home.

B

There's no increase in the number of hospice beds in the community.

B

I think this is genuinely a reflection of moving to a much safer culture over the.

B

Years and following the evidence base for reducing avoidable harm.,.

B

And, you can see on slide 13, that if we hadn't done this,, if we had stayed at the.

B

Death rate of 2007/8,, then over the next seven years, there would have.

B

Been about 300, more deaths per year,, apparently.

B

If we look at wider measures on the next slide, slide. 14,. You can see the quality.

B

Journey over a period of seven years. And if you look at the right-hand column,.

B

You can see the dramatic reductions in mortality, deaths in hospital,, MRSA and.

B

C Diff,, but we did a whole lot of other things, pressure, ulcers and falls, and we.

B

Measure and publish every month the number of serious harms in the organisation.

B

And right at the start of our journey,, we set out a commitment to try and halve.

B

The harm, we thought it was ambitious at the time,. You can see actually see over.

B

The years it's come down by much more than a half.

B

So slide 15 is a rather poor joke attempting to demonstrate our quality.

B

Strategy was joined up and if anybody works in childcare here,, there are two.

B

Separate children in this photograph,, if I can reassure you about that.

B

So far it sounds very good,, but on slide 16 we want to really tell you the other.

B

Important part of our philosophy that we are not actually that brilliant.

B

So, if you look at safety,, we've had eight, never events,. That's a large.

B

Number of things that should never happen.

B

If, you look at mortality,, we are below a hundred, but only just,. If we wanted to be.

B

In the best, we should be down below 83, and every year we have three, four or.

B

Five really horrible incidents, things that go dreadfully wrong in our.

B

Organisation which are harrowing to read and are signs of failure of care.

B

Inside our organisation.

B

For all the types about how good we are,, you only give us a band 3 risk rating and.

B

One of the things that we struggle with is checklists, which we think is the right way of doing things and we still get non-compliance.

B

So the question was: how can we get ourselves to the next level?.

B

One of the secrets of this on slide, 17 now, is back in 2008. We started a.

B

Process whereby one of our consultants every week takes home the case notes.

B

Of the people who died in hospital the previous week- and he writes a report.

B

And you can see here the front page of that report.

B

And. He doesn't look carefully at the people who are expected to die.

B

So people who are admitted to die, he ignores, people who went in ITU. He.

B

Ignores or people who were put on the care of the dying pathway, he ignores,.

B

But he looks carefully through the notes of everybody else,. Those are the people.

B

Who did die but weren't expected to.

B

He looks for themes,. Was it right? Patient, right, ward, was medication properly.

B

Checked and the next three or four pages of his report are discussions.

B

About individual cases. And that goes out every morning to all clinical members of staff in our.

B

Organisation and sometimes prompts a blizzard of debate about some of the.

B

Questions that he is raising about did things go wrong,, a very, very healthy.

B

Debate in my opinion. In addition to looking at things on a weekly basis,, he looks at things on an.

B

Annual basis and on slide 18 is the latest set of highest risk events that are.

B

Happening in our organisation.

B

So, through his analysis,, we know what else is going wrong beyond the standard.

B

Mortality and infection and pressure ulcers and falls, and he is giving us a list.

B

Of things to tackle,, so what we wanted to have a system for dealing with quality.

B

In an organisation that couldn't really afford to have an expensive quality, department.

B

So, slide 19. We wanted to not just have a few initiatives,. We wanted to have lots.

B

Of initiatives and we created something called Quality Champions.

B

And Quality Champions are people who sign up to do three-days training in.

B

Quality improvement techniques and then take on a project of quality, improvement.

B

And, crucially, the project has to be measured,, so you have got to measure.

B

A baseline, you have got to set a stretch target and then you have got to achieve that. Target.

B

Once you become a Quality Champion,. We invest a massive 20 pence in giving.

B

You a bronze, coloured identity, badge,, a standard NHS badge, but bronze.

B

Coloured,, which says Quality Champion and once you achieve a.

B

Measurable and sustained improvement,, we give you a silver.

B

Badge, another 20p. And. If your idea gets copied elsewhere in the NHS,, you get a gold badge.

B

So, a very simple and inexpensive way of recognising people for the work they do.

B

And, if you can see on slide 20,, we have now got over 280 people trained as.

B

Quality Champions, a huge force in the organisation.

B

What I describe as a sort of muscle for improvement.

B

And, then on slide 21,. You can see the 60 projects that they are currently working, on.

B

That's our system. We know the things that go. Wrong. We've got nearly 300 people that will work on them in teams and they are the.

B

Projects and in a few weeks time, I am going to be handing out some silver badges.

B

Just, to give you one example,, somebody who worked on acute kidney injury has reduced the mortality rate within six months from 44% to 36%.

B

Fantastic. And, that's just one of the 60 projects that are going ahead.

B

So I am now going to just move into the other aspect of this,.

B

Which is about staff engagement. Because? It's not just quality. That's the secret of the culture change,.

B

It's the staff, engagement, too., So, slide, 23 is back to the wheel and you can see. I am highlighting one of our.

B

Values,, which is about team work and one of the board's objectives,.

B

Which is about staff engagement.

B

And? In 2011, we had a bad staff survey result.

B

We went below average in the NHS.

B

And, you know, I am supposed to be ex-HR,. I was embarrassed by having a.

B

Below average staff survey, result.

B

We also knew that we were facing a real need to change gear, because of.

B

The economic challenges. And, we got an invitation by email to join a programme called Listening into.

B

Action,, which is about improving staff engagement, and, at the same time,.

B

We started working with an organisation called Unipart,, which again is about.

B

Engaging staff to solve problems in flow processes.

B

And, both of those things worked together for a period of 12, months.

B

And, you can see in slide 25 the extraordinary impact that that had in our organisation.

B

So in 2012,, before we started this,, we did what we call a pulse check,.

B

Asked people a range of questions, for example,: do you feel frustrated about.

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How well things are resolved on a day-to-day basis,? Only 17% said that.

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They thought things were quickly: resolved.

B

And. You can see in the right-hand column how this one-year programme of.

B

Staff engagement made quite a dramatic improvement and that's an average of.

B

30% increase in all those questions.

B

If you move on to slide. 26, people will tell you that the academic evidence is if.

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You get staff better, motivated and better involved and engaged,. Then you will see.

B

Other benefits too. Benefits in terms of HR, but wider as well.

B

And, you can see there that in that year, the temporary spend on staff went.

B

Down,, the sickness absence rate went down, and then you can see on slide 27,.

B

That at that time there was a quality dashboard for the north of England and.

B

We were fifth out of 50 for quality and we were also fifth out of 50 for.

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Performance and we were top for A&E and we achieved our financial surplus.

B

For the third year in a row.

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So, really the point I am trying to make is that when you get well motivated staff,.

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You don't just get good staff results,, you get good patient results and good.

B

Organisational outcomes as well.

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Now, the next bit is probably the most important bit.

B

Because, thanks to some fantastic individuals,, neither of the two of us,.

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We didn't stop there,, we wanted to say: how can we take staff engagement to the next level?.

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How, can we rather operate as an organisation wide,? How can we tailor.

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Something more specifically to an individual department?.

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And slide 29 is the guts of how this works.

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So slide 29 is a sort of academic construct of how engagement works.

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And, what it says is that the right-hand side is the,. What we want to achieve,.

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These are the outcomes,, so performance, staff, turnover, safety.

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Improvements, well being and so on, and that's the outcomes.

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Now, in order to achieve those outcomes from staff, move to the middle box,, it's.

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About feelings and behaviour,, and so this academic construct says what are.

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The key feelings of engaged, staff,, energy, focus and dedication and what.

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Are the behaviours you see, advocacy,, persistence and so on.

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And then, the left-hand box is the enablers,. What makes those feelings.

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And behaviours happen. So, for example,, do you feel that you have influence over your job,? Are you.

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Clear about, what's expected of you,, what's the nature of your work, relationships?.

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And from being an academic construct,, we apply this as a questionnaire to staff.

B

We say to staff on a scale of one to five,: how much influence do you feel you.

B

Have over your working life? How clear: do you feel about what people expect of you?

B

How good? Do you think your work relationships, are?.

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And so once we have done that, that gives a scorecard both for the whole.

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Organisation, but then for individual departments, which we can compare.

B

And, if you look at slide 30,, you can see the product of this.

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This is a department and you can see that the blue scores are within the.

B

Average range, the red scores are below average and the green scores are above average.

B

So, this now enables us to select from a suite of eight intervention tools designed.

B

By our OD department from the first couple of years, which can be tailored to.

B

The individual problems. If the problem is, for example, about staff relationships,. Then one of the.

B

Devices is to have an away day and draw up a team charter to describe the.

B

Behaviours that you like and there's a number of other interventions that are available.

B

If, you could look at slide 31,. This is one of the most remarkable examples of how.

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That process has been successful.

B

So ward. Five was an orthopaedic ward, next to ward six.

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Ward six was lovely,. Everyone wanted to work on ward six;, the patients were lovely.

B

Ward five next door was always horrible,. Nobody wanted to work. There, people.

B

Were rude to each other and they were very depressed and demoralised.

B

So ward five went into this process and you can see on the left. The diagnostic.

B

That came up for that ward.

B

So, they deployed quite a few of these developmental tools,. They had an away.

B

Day, they got it all out on the table,, the health care assistants,. They were.

B

Undervalued, they were treated like scum., The nurses said the health care. Assistants are just solid and unhelpful.

B

The doctors said we hate going on to that ward,. We are never made to feel welcome. There.

B

When they got this out on the table,. They all agreed. This had to change.

B

So they drew up a charter of behaviours,. Someone came up with the acronym.

B

Team, Together Everybody, Achieves More.

B

It changed the dynamic on the ward and they resolved to work better and you can.

B

See that six months later it was repeated and you can see the results.

B

That I admit, is the best result,, but on average you get something like a 10%.

B

Improvement on each team that goes through this process, and we have now.

B

Had about 40 teams go through it.

B

If, you move to slide 32,. You can now see the dramatic results, so these are.

B

The annual staff survey, green is questions that are above, in the top 25%.

B

For the NHS. Red is in the bottom, and blue is the average..

B

2011 was the year that embarrassed me,, where we are worse than average.

B

2012 is, after we had the big, programme, and I think, there's a really.

B

Important message here, again very relevant to the CQC,. You can make a lot.

B

Of progress in even one year, between being predominantly bad to being.

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Predominantly good. But, our story was about going on to be more sophisticated, working at individual.

B

Team level and if you look at the 2014 score,, the latest one,, that's the fourth.

B

Best overall staff survey in the NHS and the best for staff engagement.

B

And everybody always says: what's the red at the top there.

B

And I have to say the answer: is, it is staff-on-staff violence.

B

And we haven't been able to get to the bottom of it.. People put it in their questionnaires. -- anyway, I won't go further than that.

B

Last two slides for me, what have I learned as a chief executive that NHS.

B

Organisations are huge, full of silos and people with different priorities, but quality.

B

Is something that unifies everybody and motivates everybody.

B

If you put quality and staff engagement together with a values-based approach,.

B

You can really drive extra discretionary effort and commitment and improve morale.

B

You and your team have to model these behaviours,. If you behave even once.

B

Differently to what you are espousing,, you really undermine your message and.

B

It does take quite a long time to achieve the best results.

B

And, finally, for me on slide, 34, I mean I have known for a long time that chief.

B

Executives, don't really have that much power,. Do they -- David --. You cannot.

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Command things to be better,, you cannot say right, this A&E department.

B

Has got to start performing,, but the powers that you do have are recruiting.

B

Your senior team and getting the right people and the right culture, deciding.

B

What are the most important things, being the voice, telling the story of your.

B

Organisation, and the personal example that you set.

B

And in order to get staff on side, quality is so important because staff in the NHS.

B

Are so values-driven and the benefits we have got are from staff engagement are.

B

This huge increase in discretionary effort.

B

So, that's the sort of managerial bit.

B

Now I will give the inspirational bit so over to the amazing Dr. Prabhu.

C

≫≫ Thank you very much, Andrew., First and foremost I want to put in context, slide number 35 is my own journey.

C

I am really proud of NHS. Each year 350 million patients are seen by 1.3 million staff.

C

In my opinion and it's the easiest to lead and manage because you have got 80%.

C

Core value-based staff, who will do anything for their patients.

C

The remaining 20% I personally feel the NHS system process makes them what they become.

C

I think that's the first thing: I want to say. Secondly I want to say Andrew said there was eight, never event, and let me.

C

Tell you none of the patients have been harmed.

C

I just want to say, that. But. There were never events, but we have investigated it..

C

The third thing: I wanted to start off, thanking our staff,. It is they who have.

C

Made us successful. My own journey started in 1998,. I was appointed as a consultant paediatrician.

C

In a small DGH, 11 miles from Manchester.

C

I had no other aim, I wanted to do the best. For my patients, I was a paediatrician.

C

As destiny would have it, within two weeks, I made serious mistakes and.

C

Missed a 26-rib fracture in a six-week-old baby.

C

There were two babies with the same name, same date of birth. Next to each other.

C

I, looked at my patient, I saw very tiny bruise, I thought that baby was being.

C

Abused, I asked my junior doctor, get a special x-ray, which is a skeletal survey.

C

He didn't realise there was one more baby, so he picked up the wrong case.

C

Notes and requested for that baby.

C

He gave it to the nurse, who didn't realise she was taking the wrong baby.

C

Because she was not in my ward round and she brought the x-ray and gave it to.

C

The sister who was in my ward round,, you can see how things went. Wrong.

C

I sent the baby home without realising the baby had no skeletal survey.

C

One week later, I got a phone call from a Rochdale consultant,, a good friend of.

C

Mine, and she said Umesh, this x-ray can't be normal,. There are 26 rib.

C

Fractures and this baby is brain damaged.

C

You can see the stepfather was abusing the baby.

C

As a paediatrician, I was devastated., I was feeling sorry for the baby. I felt my name would come in the media,. I was scared,, I was frightened, but I.

C

Called everybody, sat around the table and I realised what had gone wrong.

C

So I put sick system in place, I thought that was the end of it.

C

Within four weeks, 36-week-old baby died, I, didn't make any mistakes, juniors,.

C

Nurses made the mistakes, three things, went wrong., And, I, put system in place, but it affected me.

C

I felt I was unfit to be a doctor,, let alone consultant paediatrician in charge of.

C

These babies but I met a lot of wonderful people..

C

I went to see my mentor with whom I was senior registrar.

C

He said one sentence,, he said, Umesh,. Don't do it.

C

I wanted to go back to India where I come from.

C

He said Umesh,, don't do it,. You owe it to those two babies.

C

That one sentence changed: me. He was right,, I owed it to those two babies.

C

So I came back and I had a fantastic lead. Dr. Bose,, both of us started clinical.

C

Governance, we put systems and processes in place, we headhunted.

C

Consultants with our own values. Any nurse could call any consultant in an emergency and over 19 years, I was.

C

Called twice when I was not on call, but I was able to save the babies.

C

And, that's a culture we had. We started clinical incident. Reporting. Consultant led handover,. Everything was started.

C

Because of that, at the age of 42. I was asked to be medical director of Bury,.

C

I told my chief registrar, Philip, Bacon, no, I, don't want a heart attack.

C

He said no, Umesh, we can spare you, but something happened,. Somebody.

C

Challenged me and I took the job,. I was shocked, 1998 story.

C

I had 580 patients waiting for first appointment for to be seen by a.

C

Consultant for more than a year.

C

I had 300 patients waiting for their surgery for more than 18 months.

C

Out of them hundred were waiting for simple joint injection for more than a year.

C

When asked to two orthopaedic surgeons, who were messing. The system, one of them said Umesh,, give me waiting list. Initiative, I will do six joint.

C

Injections over four hours.

C

I felt sorry for the public. I felt sorry for the leaders. I felt sorry for the NHS. But I took control. I had a fantastic... We finished a joint injection within three months on one condition,. These two.

C

Consultants didn't get the benefit.

C

I still look for bomb under my car.

C

If I had my way, I would have sacked them, but system was very difficult at that. Time.

C

But at that time, I collected 27 patients who were at harm due to doctor's.

C

Mistake and I was asked to dismiss three doctors, by my board.

C

And they were BMEs, but when I look at each and every case, there was systems failure.

C

I told the board, it is wrong to blame one doctor, one nurse, to destroy their.

C

Career when there are systems failure.

C

What was interesting, was when I met the family, I personally, myself met them,.

C

I was very honest,, not one wanted me to dismiss the doctor,, including the mother,.

C

Who lost her five-month-old child with meningitis.

C

A&E junior doctor came from Pakistan,, never seen children,. He was put in charge.

C

Nurse tells him don't send the child home,. She says I'm, the doctor, nurse.

C

Rings my junior doctor and he says I am happy,, can I send the child.

C

She says,, without seeing the child,, send the child home.

C

I met the mother, I, even remember, I was holding her and I was crying and.

C

She was crying., I said: I can't bring your child back, but I will make sure no other mother goes.

C

Through what you must be going, through. And I asked you. What do you want me to do with that doctor,? If I have him dismissed, his career will be spoiled.

C

She said, Doctor,. You sound like a nice human being,. If you think you should.

C

Dismiss,, do it but make sure no other mother goes through what I'm going through.

C

Then I disciplined him and I became a mentor,. Today he is a GP.

C

Second one became consultant radiologist and third, one became staff reg.

C

So I started giving lectures around the country. Why do doctors make mistakes,.

C

It became my passion.

C

I became NPSA board member as a non-executive director and then I.

C

Became NCAS adviser,, one of the best jobs I have done, the best institution, I.

C

Have worked, for. 14,000 doctors have been referred. For 14 years, I was senior, advisor, I was advisor to NCAS.

C

I gave advice to three hundred medical directors.

C

I saw tragedy after tragedy.

C

Today in this country, 450 consultants have been suspended or stopped from.

C

Working,, similar number of GPs have been stopped from working.

C

We are trying to remediate and 40% are not remediable, because we leave it,.

C

We leave it and entrenched behaviour, and they are not willing to change.

C

I was a poor leader when I was medical director of Bury, I had short temper and.

C

Anger and spent 80% of time fighting with difficult doctors.

C

Then I became Healthcare Commission advisor.

C

I gave advice on 22 children who have died and not one should have died,. My.

C

Heart cries for the family, and one of them was a seven-year-old girl,. Four.

C

Doctors missed a diagnosis, -- three doctors missed a diagnosis but expert.

C

Was trying to cover it up. That day, I was completely shocked., I told my wife, I had enough. Anybody can be a paediatrician.. Anybody can be a medical director..

C

I want to look at my own values, so I went for a walk and within two hours, I.

C

Realised my values,, my purpose was to make the NHS the safest and the best.

C

So I came home and said: I want to be medical director, again.

C

She said you must be mad.. I was looking for a job in Pennine and a job came in Wigan,, so I told my wife, --.

C

We live in Rochdale and the M60 is a nightmare, one hour in the morning, two.

C

Hours in the evening, I said: I am not going to go to Wigan, I want to meet Mr Foster, because I had heard about him.

C

Then I met Andrew, I realised here is a man whose passion is safety and patient.

C

Quality, much more, then his respect for staff.

C

I knew this is the place where I wanted to come, and it was two days interview,.

C

He gave me the job. And I'm, just you to tell you what we did, doing all these things.

C

Slide number 36, success is never due to one or two individuals,. Success is.

C

Always due to when we all work together for common purpose or values.,.

C

And our values in the NHS is always patient., Making sure patients get the best. Care.

C

We can ignore anything, but we cannot ignore patient safety and quality.

C

Because one day,, we will all be patient,, whether you want it or whether we like it.

C

So, what is purpose? I, like Rob McDowell,, he said beautifully slide number 37, "Living a life driven by.

C

Purpose is much more meaningful and rewarding than meandering through life without direction.".

C

Next slide 38 tells you what is behaviour.

C

Values. Is your behaviour respect? What are your values.

C

I can tell you till the cows come home. I put the patient at the heart of everything.

C

I do,, but it is the nurses who observe how polite I am,, how good I am in.

C

Looking after patients. When, they need me,, do I answer quickly and take patients to that journey.

C

Of difficult journey, so it is what people observe in you,: it's not what you see, I.

C

Can tell you I'm a good doctor, but your colleagues see what this is so value is.

C

What others observe. So, what are our values, patient? First and always,? That's not for negotiation.

C

Second, happy staff,, happy patient., As Andrew said, staff must feel we are integral part of this organisation.

C

Staff must feel I am supported. Doing a good job.

C

Staff must feel there's no bullying or no harassment..

C

70 staff raised concerns with me in the last four years.

C

My door is always open for all staff., Accountability and governance,. I am very proud of our robust governance.

C

Every week I go through complaints, litigation, coroners' feedback, staff.

C

Feedback, SUI and we come up with action, I, have a fantastic team and the.

C

Support I get from nurse director and clinical governance leader.

C

Initially it used to be four hours meeting,. Now they lost one hour.

C

Because everybody knows- and we are challenged many difficult consultants,.

C

39 consultants, challenged.

C

Duty of candour, always open and always honest, not only with the patient.

C

And public,, but also with our staff.

C

Next, forward, thinking,, respect and dignity and compassion and caring.

C

Slide number 40 you already seen.

C

For me 41 is the most important.

C

For me. Nhs must be for the patients,, with the patients and by the patients,.

C

And the second sentence is the key,: it is the patients who have got to live with the.

C

Consequences of our decision, surgeries, we carry out, medicine, we give and.

C

Mistakes we make. So. For me they are not equal partners,, they have the ultimate say and they are.

C

The major stakeholders.

C

Patient safety and quality of care is not for compromise.

C

No, patient or staff should suffer because of our poor systems or processes.

C

They are ours, and we own it and collectively we are responsible.

C

Slide 43, I am very proud,, happy staff,, happy patient because everybody wants.

C

To succeed and success is contagious.

C

When, all our staff feel well and happy,. They look after patients very well.

C

44 is about diversity, when I went, there were hardly any BME leadership, position.

C

I asked four question to all our staff and asked the nurses and the junior doctors.

C

And the GPs and the consultant,, who is a good consultant.

C

Who is a nice human being?. Who is a good team, player? And, whom do you want to see as leaders?

C

And I realised 60% of them who were, they were not in leadership. Position.

C

Interestingly, when I called them,, half of them didn't want to be leaders.

C

That is what shocked me so I told them look. Guys, I am 58,, I can sit in this chair.

C

And take my salary and take my pension in two years.: You have got 20 years,, you are letting the patient down,. You are letting the staff down.

C

It is they who have made it successful, and today I am very proud, 28 young.

C

Consultants want to be clinical directors,. Two of my DMBs want to be medical directors.

C

So diverse people, slide 45, diverse groups of people are more innovative.

C

Than homogenous groups, but we don't appoint diverse people to prove our values.

C

It's extremely important not to appoint the wrong BME leader,. Everyone must.

C

Be value-based, leaders. That is the key to our success.

C

So. Our success is due to our values,, our culture,, our values-based leadership,.

C

Our staff and patient engagement and robust governance and accountability.

C

Slide 47, values for me are simply about how we treat each other as human beings.

C

Nothing more,, nothing less., 50% of our medical leaders are BME,. 20% are women.

C

I didn't appoint them because of their ethnicity or their gender,. It's their values.

C

Four I have dismissed are all BME,. For me, that is once again not for negotiation.

C

Slide 48, I would like now to look at staff feedback.

C

I, looked at all staff feedback, 95% of staff feedback in this country, BME staff.

C

Are three to five times more unhappy.

C

So unhappy staff, unhappy, patient.

C

Because, compassion, goes,, kindness, goes, caring goes gradually,. You simply.

C

Do a job, and that is the link between patient safety and quality and BME staff.

C

Secondly,, my own opinion is because of various cultural issues,. We do not.

C

Appoint BME women, who are very good leaders in leadership positions and.

C

We have got to look at it and, in my experience and estimation,, we are.

C

Probably not appointing 10,000 very good leaders with values in NHS.

C

Amongst the medical profession. 10,000. What CQC can do, 49.

C

CQC has come a long way from where you were.

C

I am extremely proud of CQC and CQC inspection has a huge role in holding a.

C

Mirror to the organisation. We as leaders should not underestimate the impact of bullying, subconscious.

C

Bias, victimisation, plight of whistle blowers when they raise concerns.

C

I was in various meetings as a BME leader, 300 BME doctors I met in the.

C

Last two years, everybody said Umesh,. You must be joking raising concern.

C

About patient safety in my organisation.

C

I am genuinely worried for patients.

C

Slide 50,, we like locally strong leadership, and this should come from the board.

C

Very important. We got value-based,. We have two days appointment for board members,.

C

Non-Executive directors. In my opinion, NHS appoints non-executive directors for technical.

C

Skill, not for values,, not for leadership, skill.

C

They, don't get feedback for their values,. We got fantastic value-based.

C

Questionnaire, absolutely brilliant questionnaire,. We have now analysed 300 senior doctors and senior managers, senior and leaders, and we know how.

C

Much you have to score to be on the board and the whole institution,.

C

Cqc alone cannot change. Nhs.

C

All of us have to work. Together.

C

It is wrong to appoint BME just because he or she is a BME,. It is right leaders to the right, job.

C

Last three slides, 51.

C

Martin, Luther King and Mahatma Gandhi and Nelson Mandela had huge.

C

Influence on my life, and Martin Luther King said our lives begin to end the day.

C

We become silent about things that matter to us., Ladies and gentlemen, slide. 52, patient safety should matter to us, staff.

C

Well-Being should matter to us,. Nhs is a great institution, but sadly many patients.

C

And many staff suffer and together, we have got to make it the best and the safest.

C

Finally, 53,, if what you have done in Wrightington, Wigan and Leigh,.

C

Foundation Trust is not done across the NHS, in my opinion, 75,000 patients.

C

Suffer moderate to severe harm every year, staff suffer and the medico-legal.

C

Bill alone, with the duty of candour, is going to be probably £15 to 20 billion.

C

Either duty of candour will be a casualty or the NHS will be a casualty if we don't.

C

Do something about it. But I want to say,. As Andrew has said, repeatedly, we are not perfect,. We still.

C

Have a lot more to do.

C

Finally, slide 54, as I said, Mahatma Gandhi,. This slide has had a huge.

C

Influence on me., He, said, "Keep your thoughts positive. They become your words." "Keep your words positive because they become your behaviour." "Keep, your behaviour, positive because they become your habits." "Keep, your habits, positive because they become your values." "Keep, your values, positive because they become your destiny." Thank. You very much for inviting both of us.

C

A

≫≫ Well I don't see how anybody can fail to be inspired by what we have heard.

A

From Andrew and Umesh but I'm sure the board has lots of questions because.

A

To pull this off is a huge achievement,, so colleagues?.

A

D

≫≫ Thanks so much, yes,, very inspiring and interesting talk, thank you.

D

So I just want to ask the very obvious question which is Acute: Trusts are.

D

Obviously, under huge financial pressure, 75%, at least in deficit.,.

D

Can you say,, can you give some inclination about? Does this cost money to.

D

Do,, your journey. How, much of it, is really being hampered by some of the finances or really as.

D

Most of it can be done if it's relating to behaviour and values without being.

D

Impinged by the deficit, issue?.

B

≫≫ For, both the --, the two main components, I, think of the organisational.

B

Development approach are the Quality Champions and the staff engagement tool.

B

In, each of those cases, we employ a one, fairly senior member of staff to run them.

B

And then, the rest is based on discretionary effort by the people. Involved.

B

So I think that our staff engagement programme probably cost just under.

B

£100,000 a year and our Quality Champion probably costs about the.

B

Same,, a combined investment of maybe £150,000 a year in an.

B

Organisation with a turnover of about £265, million.

B

And to me, the results,, they probably could be quantified and would be.

B

Infinitely greater than that.

B

I just gave you one example about acute kidney infection,. What's the saving to the.

B

Nhs by a reduction in the mortality rate and a reduction in the length of stay and.

B

That's just one of countless,, countless projects.

B

So I think you have to hold your nerve because there will be a tendency when.

B

Times are tight to say: let's cut all non-essential expenditure, but to me this.

B

Is essential expenditure,? This is where the solution is going to come.

B

And you know, in dealing with the financial challenges that we all face,.

B

The best people to come up with the answers to how we can reduce waste.

B

Duplication, save money, are the staff that work on the front line.

B

So staff engagement is the answer to the biggest problem as well.

C

≫≫ Jennifer, poor quality costs, a lot, human tragedy costs a lot.

C

Let me give you an example, in 2008,, we had 46 fracture in the hospital.

C

This year we had only eight. Eight is too many,. Please don't get me wrong, but those 46 patients, they stay longer.

C

That's a reason: why. Number two,, as I said in the beginning,, every NHS institution has got 80% core.

C

Value based staff, if your journey is proper and you inspire them and reward.

C

Them and engage them,. They will come up with the solution.

C

Good example. Two years ago, one of our ideas was saving two million by closing a ward.

C

I had eight email from the consultant and nurses.

C

I sent one email to answer Andrew,, please don't close the ward,. This is coming from consultant. So. He sent an email immediately,. We are not going to close the ward, but he asked next question, Umesh. Where is the two million coming.

C

So? We all sat around the table and we came up with the answer and I.

C

Personally, feel, I personally, I may be one of the exception, I personally feel.

C

Nhs got enough money if we use it: properly.

C

For, example,, medicine, alone,, £11, billion,, patient, taking medicine home.

C

And not using, approximate cost £750 million.

C

I personally feel, if you have the right, leaders, value-based leaders, working.

C

Together,, not in silos, I think we have got enough money, but it needs.

C

Absolutely value based leaders.

C

D

≫≫ Thank, you very much for your presentations,. They are very inspiring.

D

And you have spoken very powerfully about the importance of staff.

D

Engagement in delivering safe, high quality, care.

D

You have said a bit less about patient engagement and I just wondered,. You.

D

Know,, what your approach to that is or was, and whether the results from.

D

Patients are as equally as impressive, or is there more work to be done on this or -- yes?.

B

≫≫ No, I haven't covered patient engagement, but yes, there is an extremely active programme of patient engagement and our Trust board gets a.

B

Quarterly report about the multiple activities that take place and even I'm.

B

Impressed by the figures. As I remember last time,. The last quarterly report said that in the last three.

B

Months, 8,000 members of the public and patients had been engaged in a.

B

Variety of activities,, ranging from we have panels of people who look at new.

B

Documents to say are they well written from a patient's point of view,? We get.

B

Groups of people to help redesign the emergency care pathway,. There are.

B

Other groups that are sort of on the Quality Champions,, wherever.

B

Appropriate,, we ask them to get a patient representative on to their project team as well.

B

So, it's just that I didn't cover it in the presentation, but yes, there's a lot there.

D

≫≫ And are your patient survey results particularly good and, following on from.

D

That,, do you think there is value in this, these patient surveys that are done?.

B

≫≫ Yes, I, certainly do. I, think there's probably a lag effect between what you do with staff and the.

B

Consequences that you have for patients.

B

But, if you look at our patient survey, results, I mean things like friends and.

B

Family test for A&E,, we have been I, think the best performing on friends and.

B

Family in A&E,, as well as being the best performing in terms of the 95% target.

B

So I do think there is a correlation.

B

If you look at -- are we,, we are in the top 4% for the staff. Survey,. Are we in.

B

The top 4% for the patient, survey?

B

No,, we are not. But. You know I'd like to think we'll get there.

C

≫≫ We have got something as always: event, always event,. It was absolutely.

C

Brilliant, ten questions, and that is what our, our volunteers go, and governors go.

C

And ask all patients and that we are scoring around 90, 95%.

A

≫≫ Emma.

E

E

>> It was a brilliant presentation.. Can I ask a little bit more about how you view CQC and its methods and how.

E

They would apply to what you have achieved?

E

Andrew,. You allowed yourself a small aside about being in band 3 in that, in.

E

Our monitoring- and it is a very important question for us, how we can identify.

E

Something which, a fundamental concept like values,, because that isn't.

E

Easy to go and inspect in the way that you can inspect how clean a fridge might be.

E

So I have got a question about what's -- how our methods might be modified to.

E

Pick up the kind of achievements that you have been able to get to.

E

And, if I am allowed a sort of second question, I, am quite disturbed by what.

E

You say about BME doctors and their place in the NHS.

E

I know that's a very large area to cover, but it's a key thing that we should be,.

E

Cqc should be concerned about, as a supplementary,. How might we contribute.

E

More to fair treatment of BME staff?.

E

≫≫ Shall I do the first bit? >> Yeah.

B

≫≫ I mean obviously we have followed the CQC and its predecessor, bodies.

B

Over the years through this quality journey that we have been on and we.

B

Were very, very impressed with the new style of inspection that's been created in.

B

The last few years. We can see why that would be more effective..

B

Some of our clinicians took part in the assessments of the Keogh Trusts, which.

B

Were right at the start of this process and we were so impressed with that,.

B

That we decided to do it. Ourselves. We have actually had four mock CQC inspections and the first one horrified us.

B

Because we found some really bad examples in a couple of areas inside the Trust.

B

The second, one disappointed us because we found some more examples.

B

Of bad things,, the third one -- I, think when you come to see us in December,.

B

You are going to find something else, as well. But as a process for finding areas that are just not emerging through your.

B

Normal management processes,, the idea of student nurses and trainee.

B

Doctors going into areas and simply asking their peers: what's it like here,.

B

That produces results. You are not getting in other ways, so we are really, really.

B

Wedded to that, and we will be very interested to see what happens when.

B

You do come inspect us in December. Just on the band 3 thing, I do feel some of the components of the bandings are.

B

Extremely technocratic and we find ourselves in fairly abstract arguments.

B

About statistics, sometimes with our CQC representatives- and we don't feel.

B

That we are talking about the sort of things that Umesh and I have presented.

B

Here today,, we are not talking about the culture within the organisation,.

B

We are not talking about staff willingness to talk, up.

B

Instead we are talking about gastro bleeds in the sort of third statistical.

B

Fluctuation,, it's bizarre stuff and I. Don't think it's absolutely hitting the button, but.

B

We haven't made a big fuss about it,. We just try and improve.

C

≫≫ Lous, I am glad you asked about CQC scoring,. Never events is a good example.

C

I think CQC inspection encourages staff to cover it. Up.

C

The pressure they come under,, never events,, not one patient came to.

C

In a short-term or medium term, harm is leaving the swab, it shouldn't happen,.

C

Don't get me wrong,, but if you give it top priority,, that's what happened, people.

C

Will cover it up, because there's so much pressure from the top.

C

Particularly, the culture of NHS,, bullying, victimisation and all those things.

C

And, if you want open and transparent culture,, what I was very proud of was.

C

We called Brian Toft to come in and look at those, never event, fantastic report.

C

And he is doing the board and what I really loved was that day,, the chairman.

C

Stood up and said in public meeting Umesh,, please tell our staff not to worry.

C

About number of never events, I want them to be open and honest.

C

I was very proud.. That is what my worry, is. I think you have got to look at that. Coming to BME,. It has been for the last ten years. I have been worried about it,.

C

Three hundred doctors contacted me,, only 40% have been treated fairly.

C

I am genuinely concerned.

C

I think that responsibility is a power given to medical directors or the board,.

C

And all the changes. I think the patients must be at the heart. You saw where I am coming from, but I think we have got to make sure --.

C

Doctors will make mistakes, because each human being makes six to seven mistakes. A day.

C

Each human being. There's a good, very American study,, so making mistake, to err is human;. If we.

C

Don't make a mistake,, we don't learn. When you put a lot of pressure, then they try to cover it. Up.

C

I think the BME issue, you have to look at it,. 14 Trusts have contacted me.

C

I am now nationally known,, that's only when I started, tweeting.

C

Nobody listened to me. I thought: okay, I am going to tweet,. I have now got 10,000 followers, in India I.

C

Have 4 million followers. I, say something, repeat, and they will do it for me. And? That's the reason why,, but that's not the way. I want to deal with the NHS.

C

I love. Nhs,. I am very proud of NHS,. I have had an amazing life in the NHS,.

C

A fantastic career,, but the human tragedy really for patient and the.

C

Doctors, we have got to do and I think CQC can do a lot more.

C

I will be contacting you,. I am now included, as advisor for the BME. I will be.

C

Able to tell you ten or twelve things you can do and it's not at all difficult to.

C

Identify what is going on in any organisation.

F

≫≫ Mike. >>, Can I just join everybody else and say how inspiring I found that, even.

F

Though I have heard it before and it is fantastic and we come across a number.

F

Of Trusts, which are really struggling on staff, engagement and staff, culture and.

F

Are at the bottom end of the staff survey and I think there are lessons for the.

F

Nhs and the point that you were making, Andrew, about it, doesn't.

F

Necessarily have to take years and years to turn this round.

F

It's a hugely important one and needs to be heard much more widely.

F

And I could point you in the direction of some --. Maybe we'll talk about that later.

F

Can I just sort of come back.

F

First of all,, your mock, inspections, I, think you are probably the record holders in having done four,. We certainly hear of people who have done mock.

F

Inspections and absolutely no problem with that, because that is the right thing.

F

To do to prepare, but four is probably a record.

F

The banding issue, I think Paul may wish to comment, I mean what we are.

F

Now, in a position, having gone around about 70% of the Trusts and rating.

F

Them,, we can really look to see which elements in our intelligent monitoring.

F

Are contributing in both directions,, which are the real risk ones, but which are the.

F

Ones that say this is a very low risk, organisation and I think we are learning.

F

That as we go, and but it's only now that we have done a large number of.

F

Inspections that we can begin to say that.

F

On never events, just to assure you, I, don't think. Never. Events in itself would.

F

Ever be something that made us make a judgment,, it's how a Trust responds to a.

F

Never event,, so we use that as a probe, and so if there are a lot of never events.

F

And if the WHO checklist isn't being used,, why not and what measures are.

F

The Trust taking to do that.

F

So I think that's a classic example of where it's not just a metric. We go by, but.

F

It's a metric plus a response.

F

Finally to comment on the BME issues, that, as you know,, we are taking this very seriously.

F

We are doing a whole lot of work at the moment. Looking at the four items in the.

F

Staff survey, KF, 18,19,, 23 and 27, which are the ones that are most important.

F

And looking, it's the gap,, isn't it, between what the White respondents and the.

F

Bme respondents are saying that we need to take into account and we are.

F

Very actively working, working with Rodger Kline on it as well.

F

But, it's not just the numbers.

F

We have been,. If you like, testing,, holding specific focus groups for BME.

F

Staff, which have only been partly successful and in some cases nobody.

F

Turns up, and in some cases we learn a lot from them and really outside this.

F

Meeting, I would love to have further discussions about what else we can do.

F

And then, of course, we do also include discussion of that with senior managers.

F

When we come to Trusts. We are learning,, I am not saying we are there yet, but we are certainly learning.

G

≫≫ On the intelligent monitoring.

G

What's the first thing I do when you talk about,, obviously I have quick look just to remind myself.

G

One of the important things for us is the things you have talked about around.

G

Never events and understanding them and around mortality and wanting to.

G

Reduce them,, those are the particular things that are coming up.

G

And I think you are absolutely right on the point about the statistical detail and.

G

It's the challenge when you ever try to do anything purely from the data,.

G

Inevitably, you have to set statistical rules and it's one of the reasons, Mike alluded.

G

To this, we are never going to judge on data alone and intelligent monitoring is a.

G

Guide for where we inspect and what we inspect when we are there, so we can.

G

Have the conversations and particularly understand the Trust response.

G

There are also a lot of indicators that are about things like the staff survey,. None.

G

Of which come up for you, because you are good on them and one of the things.

G

We are looking at is how we can more obviously highlight people who are doing.

G

Particularly well on individual indicators.

G

The question is a bit from Jennifer's question is when you are talking to your.

G

Staff about staffing specifically,, not least about seven day services,. You are very.

G

Clear about safety comes first.

G

How, do you have the conversation when they say to you? We are hearing one thing.

G

From one bit of the system, one bit from another,, what's your advice to.

G

Staff,, what do you want them to do,, specifically on staffing?.

B

≫≫ There was an example of this last summer, when we were having.

B

Unusually bad problems in A&E.

B

I say unusual, unusual for the time of year,. You expect summer to be quieter.

B

And we were having a dreadful summer and staff concerns were about issues.

B

Like staffing, levels,, visibility of patients that were on corridors and staff, I think.

B

Did feel that they were getting a slightly different message that one part of the organisation was trying to talk about budgetary discipline and another part of.

B

The organisation was talking about quality and safety.

B

So, we had an event,, we got about 30 nursing staff and a few medical staff.

B

Together in the boardroom, with the medical director,, director of nursing and.

B

Myself- and we just got them to talk for an hour and a half about how.

B

They felt about things and they drew up a list of things, assured them,. The finance.

B

Director was there as well,, so they could see. We were actually aligned in purpose,.

B

And then try to do some of the things in response to the concerns they raised.

B

And, of course, these things then get talked about in the organisation.

B

The grapevine is probably much more important than anything else you put out. In writing.-.

B

I think you are judged by your actions. Really is probably the main answer to your question.

B

Can I make two little asides..

B

I am really conscious that organisations that are deemed to be successful can.

B

Then become victims of their own arrogance.

B

And, whilst I have sort of told quite a success story for Wigan, I would be.

B

Quite worried about us, beginning to believe our own greatness.

B

Actually, your CQC band three risk rating. We used to our advantage.

B

We, don't entirely think it's a fair reflection, but it's actually part of.

B

Continuing to say to the organisation look,, we are still harming people,. Look at.

B

That mortality rate, so I don't see it as being a particular problem.

B

And then, just one final point, yes,, we have said that we have got eight, never.

B

Events in the last two years., Now I'm seconded to an organisation at the moment, which is three times as big.

B

As Wigan and it's only had one never event in the last two years.

B

Which organisation is doing worse on never events, I will leave it to you to judge.

C

≫≫ I just want to warn you Paul,. If you have value based leaders, critical, mass,,.

C

Everything is easy, because these are all people who put it -- value based leaders.

C

Are role models,? They put patient at the heart of everything they do and they.

C

Take staff with them because they are good team players.

C

They are self disciplined,, so they don't have a problem in disciplining others,.

C

And that's the reason you get. 22 clinical directors, I sent one email to them,.

C

These are issues with staffing,. They all join together.

C

Nhs creates them and us. I always say there is no them and us,. We are all in this together.

H

≫≫ Thank you.

H

I have got a real sense of the journey you have been on and the way that you have engaged and motivated and inspired people which I would call a kind.

H

Of pull,, you pull the organisation through in that way.

H

But, you have also talked about accountability as well, and you have both.

H

Talked about people that have exited the organisation because they have not got.

H

The values that you want to see and that you have talked so eloquently about.

H

And Umesh,, you have referred to this, Andrew, in terms of your A&E story in.

H

Terms of making it transparent and then a never event.

H

Can, you just say a little bit about how you square the pull and motivation.

H

Around quality and I think what you were referring to Umesh about whether we.

H

Might be contributing to people covering up and therefore the difficulty that you.

H

Have then got accountability with what you have said? About, yours, isn't the soft.

H

Fluffy philosophy, there's a bottom line in here about accountability for your.

H

Performance as a professional. Can, you just say how you bring those two things: together, and you've created.

H

That culture, where you do have accountability and you do have that.

H

Transparency and so you do report, eight, never events and it becomes a subject of discussion.

B

≫≫ If I, give you a technocratic answer. First and Umesh again will no doubt give.

B

You some inspiring examples from the world of medicine.

B

Technocratically, we have defined what the values of the organisations are and.

B

We have defined what we want the behaviours to be, and we now have a.

B

Process where all senior managers have to go through an annual 360.

B

Degree questionnaire of their behaviour against those values.

B

So, that is entirely designed to give feedback to people,. Are you behaving in.

B

The way the organisation wants you to?

B

And, you know,, our philosophy is very much hold the mirror up to somebody.

B

And get them to change their behaviour first,. If that doesn't work,, then we would.

B

Get rid of people. But in practice, in my entire life as a director,, I have only actually got rid of two people.

B

Other people may have gone because they felt they didn't fit.

B

But, it's this actual holding people to account, this exposing them,. It's telling.

B

Them look, your colleagues say that you are not living this particular value.

B

That's, what makes the change.

B

It's that comment about the standard you live by is the one that you don't walk.

B

By,, it is holding people to account and making it clear to them.

B

So, that's a systematic answer,, but Umesh I am sure will give you...

C

≫≫ David, I become very emotional when I talk about our consultant colleagues and staff in the NHS, 80%. Don't give me any headache, day in and.

C

Day out, work so hard for their patients..

C

There are some consultants I can't afford their salary.

C

I tell you very honestly,. These guys are simply amazing.

C

I can repeat name after name in our Trust.

C

20%,. They become what the NHS makes. Them.

C

We are not good at holding the mirror. Early.

C

We leave it,. We leave it. It's like you pass the driving test,, you jump orange light,. Nobody catches, you.,.

C

You start jumping red light. Ten years down the line you genuinely believe that's the way to drive.

C

In Wigan, everybody I hold the mirror,. Anybody can come to see me.

C

80% of them said Umesh,, it won't happen. Again,, I'm, sorry.,.

C

80%. Andrew gets a copy,, they get a copy of it.

C

So. We know exactly what's going on. Five consultant, whose name repeatedly came when I went, all five had been.

C

Addressed, because I got a robust system.

C

And everybody said this guy technically amazing, but absolutely atrocious to everybody.

C

When I wanted it. Tackled, no consultant wanted to use their name.

C

I put system in place, and one day he was so rude to a 92-year-old. Lady I was shocked.

C

He was called. First time, I told him nicely, second time, I told him, third time he got a final warning,, no more complaints in the last 18 months.

C

Six have gone because I got email about bullying and everything, I told.

C

Them these are against our values,. I am going to investigate and two of them in.

C

Front of GMC, because I found out what happened after they left.

C

In, a good organisation,, good system, good staff become great.

C

Poor staff either leave or you identify and -- and NHS core values are so.

C

Good,, when you hold the mirror with the evidence,, what we do is we talk behind.

C

Their back,, we don't hold the mirror.

C

Then, we say everybody says you are rude..

C

How would I feel. If somebody tells you Umesh,, everybody says you are rude,. I will be upset.

C

Whereas, what I do is on Wednesday, in the meeting,. This is how you behave,.

C

This has been brought to my attention, I want to have a discussion and the vast.

C

Majority realise- and that is what we have done in last two years,, no reference to GMC.

C

No rudeness by any doctor. I used to get 16 a year to the patient.

C

And. That's what it is. And one good example and Andrew one day, I sent an email to nurse director,. It.

C

Was not rude but language -- I was upset.

C

Within five minutes, Andrew sent me an email, Umesh,. Would you like to reflect on the email.

C

None of us are perfect., We are all human beings. The day. We think we are perfect, it's time to retire.

A

≫≫ Well I, don't think any of us can. Thank you enough. This morning, I think the.

A

Spirit of what we have just heard is hopefully going to infuse the rest of our.

A

Day, but much beyond that.

A

Sort of a last word from me, I think I have been impressed,, I mean I sat next.

A

To Andrew at the dinner last night and I was looking at the board performance.

A

Report that the Trust produces and I think in some ways, it's this combination.

A

Of hard data, and not escaping of the data, says and values.

A

And, if you put data and values, together, I think you do have this.

A

Wonderful combination that we have heard about this morning.

A

So,, thank you very much for coming to our meeting,. You have had to come a long way.

A

But, we are extremely grateful and I. Think all of us have learned a great deal from this morning.

A

A

Right, we have lost a couple of board members, but we have now got the least.

A

Important part of the agenda to go through, first of all,, we do have.

A

Apologies from Paul Corrigan, and he was really extremely apologetic in his.

A

Email to me- and he was very worried- that we might all feel that this was one.

A

Board meeting too many that he had missed, but I reassured him that when.

A

He is at a board meeting,. He is extremely valuable. Member of the board, so...

A

We have got the minutes of the last board meeting, which was obviously the.

A

Frimley Park board meeting, which actually I couldn't go to is --, are all.

A

Colleagues, happy with the minutes?.

A

Robert. You have them?.

I

≫≫ Yes, they are.

I

It's important. They are because we, for obvious logistical reasons. We weren't.

I

Able to televise the meeting and put it on the web.

A

≫≫ I'm glad it went very well because I think we need to,, David and I,. You know,.

A

We have already started discussing where we can have our next, as it were,.

A

Site based meeting, I think it sounded from all colleagues that it was a really.

A

Valuable,, it was really valuable to get outside of our building.

A

The next item on the agenda is David's report.

H

H

In fact: the presentation from Umesh and Andrew stands in a sense as.

H

A benchmark against which we can compare much of the content of this.

H

Report,, which is effectively a report on our performance and an update on a.

H

Number of key issues.

H

I am quite happy to be interrupted, Michael, by colleagues. If that's what you.

H

Would like to do.

H

But I will go through it at some speed.

H

There is attached to this report a performance report which has some of.

H

Our key metrics in,- this is not the full report,. You agreed at the previous.

H

Meetings that we would take a monthly update report, as well as a quarterly main.

H

Report in terms of our performance and that monthly report is here.

H

And the key issue to pull out and it's flagged in the paragraphs on pages 1.

H

And 2 and the top of page 3 is our performance against the number of.

H

Inspections that we have set to complete by either April '16 or September '16,.

H

The end of the roll-out of this first phase of inspections.

H

And, what's clear from both the graphic and from the reports which are here,.

H

Is that the current trajectory will not see us complete that piece of work.

H

So, what the senior team are working on is what action can we take to develop a.

H

Plan which will see us realistically, not unrealistically but realistically, put in.

H

Place measures to actually see that that programme of inspection work can be delivered.

H

What I'd like to suggest,, Michael and colleagues,, is what we do is let that.

H

Work take place over this next few weeks and bring back to the October.

H

Board meeting a report which sets out the work that is in place.

H

A number of colleagues were at the regulatory governance committee last.

H

Night and it arose as a matter of arising from the debate on adult social care at.

H

Your previous meeting and indeed, Louis,, you chaired the conversation.

H

Around what we have learned in relation to primary medical services and how we.

H

Take that forward. I don't want to stifle the debate or questions, Michael and colleagues,, but.

H

Actually that work is ongoing and what I'd like to suggest is we bring that back.

H

The figures speak for themselves and we have a fuller debate when we have.

H

Got the concrete actions in place and we can speak with some authority about.

H

What is actually being done,, as distinct from what is being planned.

H

Perhaps, if I just pause there on that issue, because it's a big issue and it's a.

H

Probably an issue that non-executive directors would want to make comment. On.

D

≫≫ Yes,, we did discuss it last night and I was very kind of struck by the comment.

D

That Anna made at the meeting that what is plan B,, that was her kind of challenge.

D

But that I think was around,. You know, making sure that we hit the targets, but.

D

Also make sure that we focus more on organisations that are of concern so that.

D

We do,, if you like,, inspect everywhere,, but maybe take a much lighter touch at.

D

Those that we don't have concerns about.

D

And I think that's quite,. It could be an important kind of decision really.

D

Because if it's lighter than we are currently using,, then I think there's.

D

Some value in that., But I think it's also something we perhaps need to think about, to make.

D

Sure that we do deliver on what we have committed.

D

Perhaps Anna will explain it.

J

≫≫ Elaborate and just, in case it is helpful.

J

So, it was --, I was kind of suggesting that we might do something lighter touch, but.

J

The reason was not to introduce a lighter touch regime,. The reason was.

J

Whereas in the hospital arena, I think we are much more confident that we know.

J

From the data that we have,, that we have gone into most of those hospitals.

J

Which we think are most problematic, actually already.

J

We can kind of put our hand on our heart and feel confident about that.

J

So. If we didn't complete the programme in hospitals, I think we could probably.

J

Say we are confident that those that remain are less likely to be less concern,.

J

Of course we could be wrong, but we have got better reasons for concluding that.

J

In the case of, I was talking about primary medical services. Last night, in.

J

The case of PMS and the other work that Steve is responsible for and.

J

Certainly also I think in the case of social care,, our dataset is much more limited.

J

But, what we were hearing from the PMS team last night was that actually.

J

They had the best source of kind of intelligence that they had about where.

J

There were problems,, particularly about GP surgeries,, was where either they.

J

Had had intelligence from people like the Local, Healthwatch and others who were.

J

In touch directly with users of the service,, or indeed from the first hour of the inspection.

J

That, the inspectors were getting pretty astute at kind of picking up the signs.

J

And symptoms of problems very quickly in the inspection process.

J

And so I was just saying: if that's the case,, maybe we could make sure that.

J

We have been into everywhere,, if that's one of the ways in which we can identify.

J

The problem places,, we could make sure that we have been into all of the GP.

J

Practices for that precious hour and that we do the more detailed assessment.

J

Inspection in all of the rest, in all of ones that are proving, looking most problematic.

J

Meaning that perhaps at the end of the year, if we haven't got everywhere, we.

J

Could put our hand on our hearts and say: we've been to the ones which are most problematic.

J

It's less a light touch inspection, regime,, more a,. If you could.

J

Work out what the best indicators are,, where we don't have good data,.

J

Of where the problems are,, so we could all be confident that if we don't go everywhere, we've gone to the places we truly believe are the most.

J

Problematic, so I wasn't suggesting it was the only solution or the right one. In.

J

Relation to GP, practices, I am just saying we probably need some other ways to.

J

Give ourselves confidence that we've been to the most problematic locations.

K

≫≫ Thank you, Anna. I mean the debate over at last two hours. Late night was extremely helpful for us.

K

And what you are suggesting is really important for how we take the model.

K

Forward after next September particularly,, but in the year, I think our.

K

Work with Healthwatch has really helped us focus,, as you say, on the practices at risk.

K

Intelligent monitoring,, even though it did receive not the best press. We have ever.

K

Had, has helped us a lot in prioritising those practices and also looking at the workload.

K

So, when we are saying it's a very challenging target next September, part.

K

Of the problem, for example in London,, even if you put recruitment and things.

K

Which is now very good, but delayed, to one side,. You are looking at a lot of.

K

Practices in London, which we are very worried, about.

K

The problem with that is you then end up with even more days of re-inspection.

K

And enforcement.

K

And I was shocked at how bad a small percentage of practices that we found.

K

Are,, some of which we have no intelligence from the CCGs and the area.

K

Teams before we go in. We are still finding a few, which are a great surprise.

K

If, you look the 63/64 special measure practices,. That means there's at least.

K

315,000 patients who are not getting care that any of us around this table.

K

Would expect, and so the level of enforcement, particularly in London, has been very high.

K

So, we are doing exactly what you are suggesting and looking at the risk and.

K

Prioritising those- but there are still surprises so I think you are absolutely right to say- and it's probably the same in social care,, that the inspection is so,. So.

K

Important and I think the more mature model, after September, will look more.

K

At how we get more of that evidence to make judgments about what the interval.

K

Of inspection is, and that's the whole aim of working through the strategy.

J

≫≫ Just one, I absolutely understand that and I think all our, to revert to the.

J

Fundamental, David said in the meeting last night in a very impassioned and.

J

Appropriate way that he was determined that we would hit the target that we have.

J

Set ourselves,, so what I'm suggesting in no way should deter us from that.

J

But I think the board also needs to know that when you come back to us in.

J

October,, if there is any risk and you know,, it is quite high risk that we are not.

J

Going to hit that target in one or all three of the sectors,, we do need you to.

J

Be able to tell us what the plan would be and I was, I mean I. Think the.

J

Fundamental point I wanted to make was that the plan B for me needs to be.

J

To give us confidence that we have, that by whatever means,, we truly believe that.

J

We have gone to those places which are most problematic.

J

Now for you to tell us how that happens and whether or not you have got the.

J

Right data or whether you need to use other tools, but it might mean flexing.

J

The approach slightly in the last part of the year in order to make sure we do it.

J

That's all I was really --. That's the fundamental.

H

≫≫ If I could just add to that, Michael.

H

So last night after we had the board dinner, I in the sad way, I conduct my.

H

Life, I got my iPad out on the train, home and I started doing the email.

H

There was an email from a inspector, saying: I am confused about what I am.

H

Expected to do,, please in your next message, set out what it is that we are.

H

Expected to do in relation to this. I thought their presentation from Umesh and Andrew really nailed this issue of.

H

How you combine money, quality and targets, and they are at a level, and it's.

H

Safety that trumps over those things.

H

I thought it was wonderfully well presented in its simplicity.

H

And somehow,, we have lost that combination of those things in the way.

H

That we have had an internal conversation about this.

H

What I tried to say yesterday evening and the opportunity to repeat it again.

H

And I will try and set this out in a message to all staff on Friday, is what.

H

We are doing in October is bring forward a plan which demonstrates what can be.

H

Done to achieve the targets, I think that picks up on the point that you were making.

H

And, in the light of the number of staff that we have got,, that was the next item.

H

On this agenda,, the recruitment process.

H

And, in light of the number of safeguarding referrals and the number.

H

Of concerns that get investigated, the amount of enforcement activity,, whether.

H

We have got the resources that can actually meet the volume of work. That's coming, in.

H

And we'll set that out and I think the issues then about plan B, Anna, come.

H

Out of that, and what we have got is a trajectory which isn't a extrapolation of a.

H

Straight line of a current performance,, but takes into account current activity.

H

And the run rate of that current activity and the change in dynamics,. So that's.

H

What I would hope to bring,, not hope,? That is what we will bring to the board,.

H

To the next meeting of October that we'll set that out., And I think the executive team's challenge,, our challenge, collective.

H

Challenge is to set that out as clearly as we can; for you at the board. Meeting,.

H

To scrutinise and challenge us on that and for us to engage the staff in the way.

H

That we have heard earlier about this is our purpose,. This is what we are here to.

H

Do- and this is how we actually should actually be delivering that purpose.

H

That's, what we have got to try and set out clearly and bring to the board for you to challenge.

H

So I am not looking to avoid a debate,; rather, let's set that out and scrutinise.

H

The plan that we have got to deliver against what we have set out to do and...

H

Yeah,, that's all.

A

≫≫ I think just one point from me.

A

I think what David and the executive team brings back in October is going to be important.

A

But I also think beyond October,. We probably need to have a more.

A

Fundamental think about how we operate.

A

David mentioned to me that in adult social care, for example,, an inspector.

A

Probably makes one visit or does one inspection a month and, of course,.

A

There's so much else for them to do.

A

But, it does mean the,, as it were, front line. Time of an inspector is very limited.

A

Yesterday, I went on the, a part of the unannounced inspection of Guy's and St.

A

Thomas's and the inspector I was with said you know,. It's often six weeks.

A

Between inspections and the time, that she spends during the six weeks is.

A

Writing up the reports,, you know, various other kinds of work.

A

And, whether we can change this balance between our inspectors on the.

A

Front line and our inspectors sort of back at home or in the office, I think, is a.

A

Fundamental question for us. I: don't expect that can be answered in October, but I do think it's a question that.

A

We need to think about beyond October.

A

Because we are going to be facing this productivity challenge and part of the.

A

Challenge I think, is this balance between time on the front line and time on.

A

Administrative --, the administrative side of work, report, writing and so on.

A

David,, do you just want to touch now on the other couple of items in your report?.

A

≫≫ Thank you, Michael.

H

So,, the performance of the recruitment team in HR on recruitment is set out in.

H

Paragraph 2 and speaks for itself, 538, inspectors,, 79 managers.

H

And, you can see that the recent adverts have provided a very strong long list of.

H

Potential candidates which is now being processed, and that goes beyond.

H

Inspection directorates and includes analysts, who are also critical to our work.

H

Some 386 of those inspectors, of the 538, have gone through their own.

H

Specific induction and are now coming into services and beginning to.

H

Be productive and begin just to pick out one of the things from last night,.

H

The inspection manager who was supporting Steve's presentation, talked I.

H

Thought very well of the ability and the strength of those inspectors in relation to their role.

H

You have got the updates from Mike,, Andrea and Steve in relation to current.

H

Issues and current performance,, which build on the performance report.

H

Andrea's teams have been dealing with the Old Village School, nursing home.

H

Which has received some publicity. So, we have covered both what we found in that inspection and the subsequent.

H

Activity that is taking place and then the learning from that activity is set out on.

H

Page 6 of this and Andrea is overseeing that and there's an opportunity if.

H

Colleagues wish to ask questions and then Andrea is quite happy to fill in the detail.

H

In a similar way, on hospitals,, it's not to gloss over Steve's work, but on hospitals,.

H

We have set out the performance and activity since the last board report and.

H

Similarly, if board members wish to raise any questions with Mike on.

H

Addenbrooke's,, given the publicity yesterday, I just want to actually provide.

H

That opportunity and Mike stands ready to answer those questions.

H

Is it worth just pausing at that point, Michael and then I will go through the rest of it.

K

≫≫ Steve. >> Thank you. Not to gloss over primary care, but this week is a significant week for us in that.

K

The first practice to come out of special measures will be published. Tomorrow.

K

And in the report,, we have also got a practice which was rated inadequate.

K

Before we brought in special measures,, there was about a month over.

K

And that has now been re-rated, as requires improvement, and we are.

K

Showing improvement now in many of the practices that we are going back, to.

K

Sadly,, as we are inspecting special measures practices,, we are finding.

K

Some which aren't and their reports will be out in three or four weeks' time, but.

K

Tomorrow's announcement is a big one for us as a board,, because it does show.

K

That special measures for us in general practice,, just like in hospital,.

K

Is not meant to be punitive,, it's actually to say these practices need.

K

Extra support and if they get that,, then they have a chance to improve.

A

D

≫≫ Yeah I mean following on from that and for the Addenbrooke's situation,.

D

I mean there was a lot in the media yesterday, and some of it was thoughtful.

D

And constructive,, but also I, think it really missed the point of special measures.

D

Because special measures is actually there to support organisations.

D

It's not -- as Steve said,. It's not punitive.

D

And I just,. It just feel it's such an important message to get out there. For,.

D

Well, for CQC, and also for staff and the public, that special measures actually.

D

Can be a very positive thing and it's not a sort of punitive thing that some people.

D

Portray it as and actually it is quite supportive.

E

≫≫ On Addenbrooke's, Mike,. There was so many things that the report and the.

E

Coverage of it raised, but just a couple to highlight.

E

It's going to be a major theme for us over the next months and couple of.

E

Years, this question about how we reflect the financial pressures that.

E

Organisations are facing when we are judging quality.

E

To, the point where we'll have to have a broader public position on that,. It can't.

E

Just come up when we have to talk about a particular inspection.

E

And, we will have to show a sensitivity to the pressures that Trusts, clinical staff.

E

Face because of money, and yet at the same time, make clear what we are.

E

Giving priority to,, which is the safety and safety of patients, quality of care, and so.

E

On, and getting that right, pitching that right without looking like we have.

E

Adopted a sort of hard line position, I think, will be absolutely crucial.

E

I thought you did very well in doing that. Actually, Mike.

E

There is a second issue which is about what we,, how serious is a safety.

E

Problem unless we demonstrate actual harm.

E

And it's the sort of frayed tightrope phenomenon.

E

You know,. You see a frayed tightrope,. You can reasonably assume that's going.

E

To soon lead to serious harm.

E

But, not everything is as straightforward as that and there's, therefore, a need to.

E

Explain why we are so concerned about what sometimes sounds like process.

E

Measures but actually, are likely to at some point lead to,. They are the frayed.

E

Tightrope,, whether people recognise that or not.

E

And, then my third point is about learning across the NHS.

E

For me, the most striking thing about the Addenbrooke's report was what it said.

E

About maternity, services. Because, what it said was that the people weren't doing risk checks on.

E

Thrombo embolism, there was failure of monitoring of heart, rates, foetal heart.

E

Rates, there was a problem with getting senior staff to check on important signs.

E

Like heart viability and then, of course,, this extraordinary thing about nitrous.

E

Oxide, having been allowed at dangerous levels for the previous two years, I didn't.

E

See very many of the comments referring to this part of the report.

E

But the reason that that was so concerning, it sounded just a little bit too.

E

Like what happened in Furness General, for my liking, not the same, but there.

E

Was some elements of it which sounded like the early stages? Of,? The lack of risk.

E

Prediction,, the lack of closer assessment.

E

And I just,, and coming so soon after we have seen the report from Bill Kirkup.

E

About Morecambe Bay,, there is a serious question here about how some.

E

Of the findings from those kind of inquiries, or for that matter from.

E

Individual high profile reports are then played out across the system.

E

Because, it is an extraordinary thing that any service could have those kind of.

E

Failings at a time when maternity services are simultaneously under such.

E

Scrutiny because of such serious consequences and that message,.

E

How do we ensure that what's identified is played out across the system?.

F

≫≫ Mike. >> Should I come back on both of those.

F

And. Thank you for the comments. I think trying to get across the message that special measures is not punitive,.

F

I can assure you that was in all of the pre-records I did,, not necessarily in all.

F

The live ones and what I was saying was actually,. It's about at least three things,.

F

Firstly, it flags our serious concern about the quality of care.

F

Secondly,, it indicates that we think they need support to turn this around,.

F

The current leadership, as it was,, was not going to be able to do that within a.

F

Reasonable time and thirdly, it's a wake-up call to the local health.

F

Community as well to say, actually,, you need to get engaged here as well.

F

So, it's all of those things. But. Having said that,, I am not sure that probably got across on what was.

F

Actually, on the TV screens.

F

Of course on the finance side, yes,. We are very mindful of the fact that there.

F

Are financial difficulties across the NHS and, as we did say, yesterday,.

F

But some are managing this a whole lot better than others.

F

And, as we heard from Andrew, Foster and Umesh,, actually good quality does.

F

Not necessarily cost more,, it may be the opposite and I think in the case of.

F

Addenbrooke's, yes, there's a financial haemorrhage there,, but that is partly.

F

Because they are not managing their flow through the hospital, because they.

F

Are not managing their flow through the hospital, they've had to open up more beds, because they have opened up more beds,. They have diluted their staff.

F

Too thin and they have got agency staff come in and it's a vicious circle.

F

Downwards in all ways,, which needs now to be turned around.

F

The issue of risk of harm versus actual harm is one we debate long and hard in.

F

Our quality assurance group meetings.

F

But, as you have clearly read the report,, you know,, where things like proper.

F

Checks on equipment,, not instant, reporting,, cardio topography,, those sort.

F

Of things are not being done, properly, there are serious risks and they need to.

F

Be put right and I hope and believe that they will already be putting those things right.

I

≫≫ Just, following really up on that and actually trying to marry it up a bit with.

I

What we heard from Andrew and Umesh.

I

Firstly, the explanation of why things are evidence of lack of safety,. We all around.

I

This table probably know if you don't do foetal monitoring,. Babies are seriously,.

I

Seriously harmed and huge suffering can be caused.

I

That's, why it's done. But the public who read our reports, might not understand. That.

I

So I. Just wonder whether there's some aspect of that which perhaps we could.

I

Do a little more about. The other is this..

I

Umesh was telling us very eloquently how we don't blame people when there's.

I

A problem, we look for the cause for that, and then we try and put that cause.

I

Right and that's I think what we are all signed up to: try to do.

I

Yet, without wishing to comment particularly on the merits of this.

I

Particular case,. What we see in when we issue an inadequate report or when.

I

Monitor does something similar, is. The first reaction has been the anticipation.

I

Of it is the departure of leaders from an organisation.

I

Now I don't want to comment whether that's the right thing or the wrong thing,.

I

But I just wonder where we get either through our reports, or what happens.

I

Afterwards, any open and transparent review of what it was about. The system.

I

That led to things being found as they were?.

I

Now,, you have explained there Mike some of the reasons around the staffing.

I

For instance,, but actually what I'm getting at is where we have discovered.

I

Deficiencies in leadership for instance,, we quite properly, what we do is we go.

I

And see the,, we look at the outcome of that and we diagnose that. That's means.

I

That the place hasn't been well led., I wonder where, in the system, anyone seeks to explain why that happens. So.

I

That we don't keep on repeating failure.

I

Because. We have a system in which chief executives are still leaving at the.

I

Rate, every two years,, and as long as that happens, it's very difficult to see.

I

How the culture of fear that Andrew and Umesh have abolished will ever go.

I

I, just wonder whether we need,, perhaps with our partners and.

I

Stakeholders, to look at a little more, how we seek to explain openly rather.

I

Than someone goes, someone else comes in,. Everything is going to be all.

I

Right,, sometimes it is, what it was about. The system that caused things to occur.

I

Because it's never just the chief executive,, it's never just the money,. It's.

I

Never just the medical director, there's a lot more to it than that, and until we.

I

Understand those things,, it's going to be quite difficult for lots of people in the.

I

System to put them right.

F

≫≫ I think you are absolutely right about that.

F

I think we get much closer to that diagnosis of why, than we ever have.

F

Before with previous inspections, systems, and I think the advantage of.

F

Looking at a whole Trust at one go with a large team and looking at different areas.

F

And also obviously, meeting with the senior staff and interviewing them and.

F

Also, listening to other members of staff, does help us to get to that.

F

Coming to a confident diagnosis that we can say- and this is the sequence of.

F

Events that led to it, I, don't think our methodology allows for that. But we do of.

F

Course then, put together what we know about the Trust which comes in our.

F

Report with what Monitor or TDA have been finding over time and I think our.

F

Experience with the special measures Trusts is now helping us to understand.

F

What the factors are for success at coming out of special measures or not,.

F

So that we can collectively act much more quickly and one of the clear.

F

Factors that's already come out is whether a Trust does accept what we.

F

Have found or goes on denying it.

F

If, they deny it,. That is undoubtedly a factor for not making progress. Quickly.

F

So, we do know that, and so we do have. Obviously the intensive discussions with.

F

Monitor and TDA about what is needed to put things right.

A

G

≫≫ To add to what Mike was saying,. There's the what deeper diagnosis.

G

Happens following our intervention, as it were.

G

As Mike says,, that's increasingly, where Monitor and TDA are going as they.

G

Morph into NHS improvement, and there is that predictor of how quickly people.

G

Come out, how quickly they understand what the underlying challenges are and.

G

Get round to the solutions and that,, but there's also the overall system level,.

G

What are the repeated factors and, what's making the difference?.

G

So one of the things that's come out of the five-year forward. View, that's now a year or so old, is a series of sub-boards delivering the governance way of it,. One.

G

Of them is information, just for example,, but one that's just been created,. The six,.

G

Seven, now, chief executives, all have a seat on is the leadership development.

G

Quality improvement, side.

G

Now, that's just starting but I- think the test of its success will be its ability to.

G

Understand what are the actions that need to be taken nationally in support of.

G

The individual problems that get diagnosed locally.

G

So I think there is this two-tier approach to improving leadership and leadership.

G

Development and quality improvement,, which are two sides of the same coin.

A

J

≫≫ So just pursuing that a bit more, sort of a dimension of Robert's question.

J

Which I think it's important? We have a narrative about,, which is the discussion.

J

That is going on out in the world at the moment about the number of, about the.

J

Movement of chief execs and the relative difficulty of recruiting people into.

J

Those roles going forward. And, there's a bit of that narrative, which is something about the contribution that.

J

We,, because of our approach to the inspection regime, are making to that being the case.

J

And I don't think,, not necessarily looking for an answer right now, but I just think.

J

It's --, I, think embedded in your question, Robert, in a way is an important thing.

J

For us to understand is whether we are having the right impact on senior.

J

Leadership in their response to our inspection, findings, or some perverse.

J

Consequences,, which are adding to the problem of movement of chief execs and.

J

Others around the system.

J

That's a really difficult thing to guess at, but it's an important thing for us as an.

J

Organisation to be able to comment on with some confidence.

J

Now, some of the solutions will undoubtedly lie not in our hands,, but in.

J

The hands of the group you have just described,, which is I, am sure, would be helpful and able to make a contribution across the piece,, because it's not just.

J

What we do,, it's also what Monitor and TDA and others do and NHSE in.

J

Particular, but I just think for us to have a narrative about the impact that we are.

J

Having and how confident we are about the impact that we are having on chief.

J

Exec movement is an important thing.

A

≫≫ Good, I think we should -- David, unless there's anything else. That...

H

D

≫≫ Sorry, I was just going to make a quick point,. I was really interested in how the Trust we have just heard from had its own self diagnostic and much.

D

More powerful than having somebody externally tell you what they think is.

D

For you to self-reflect and understand that,, so this group, that's forming,.

D

Wouldn't it be good if they kind of developed a self diagnostic that we.

D

Could all agree on because there's tons known about what makes for success or.

D

Not, in the academic literature there's been masses written both here and.

D

Abroad, some sort of self diagnostic we could possibly use ourselves in the future.

F

≫≫ Can I just comment on that,. We do now ask in our provider information.

F

Request for Trusts to do an assessment using our five key questions and against.

F

Their core services. What is interesting, is which Trusts get it very close to what we then find, and they.

F

Are therefore in tune with both our system and, what's going on in their.

F

Organisation and which get it substantially, wrong.

F

And, some of them,, it's a very,, very different picture that we feed back to.

F

Them from the one that they gave to us.

A

≫≫ Well, just one final point, I, think one of the members of the leadership.

A

Workstream that Paul mentioned is Catriona Percy,, who was at our CO and.

A

Chair feedback session that David, Mike, Paul and myself attended a couple of weeks. Ago.

A

I saw her a couple of days ago, and the first thing she is doing is going to.

A

Wrightington Wigan and Leigh to understand how you can make this very.

A

Large change in staff, attitudes and commitment to values so quickly.

A

So I thought that was a very encouraging sign.

A

I think also to take Jennifer's point,. The fact that this Trust, Andrew and.

A

Umesh's Trust have now carried out four inspections and if you read the.

A

Inspections, they are so much like our own,. There is no question, they are.

A

Modelling, what they do on what we do, and I think that is in a way of,. If we are.

A

Thinking about our impact, which we have to worry about the whole time,, this.

A

Particular example of you know the way they inspect themselves, I think is an.

A

Excellent example of how we have impact that we don't even begin to measure.

A

I think we can now move on to two other topics that are on the agenda and to.

A

Some extent, you know, fit with the themes we have been discussing. Today.

A

Fit and Proper Persons and the Duty of Candour and I think if we take Fit and.

A

Proper Persons or Fit and Proper People, I am not quite sure what the.

A

Right, plural, is,, I, think, Paul and Mike,. You are going to just...

G

≫≫ So Mike is going to do Fit and Proper Person and I will do Duty of Candour.

H

≫≫ Just one thing, just for the record,, can I mention the staff survey and I.

H

Don't want to gloss over it,, but that's not an invitation for anybody else to speak.

H

So can, in the context of Andrew and Umesh's presentation,, we are today.

H

Publishing publicly our staff survey,, this is being circulated this week to every.

H

Director in quite fine detail about what directorate and team scores are coming, through.

H

I am not going to go and present it because of the urgency around time and.

H

We have got other guests waiting to come and join us today, but there is.

H

Some very good news in this staff survey of continued improvement.

H

We are also being very transparent about where there are continued.

H

Development areas, mainly around communication.

H

Our engagement scores are very high,. We need to understand better why we.

H

Have got improved staff engagement and we have got poorer communication.

H

Going on in the organisation- and we need to understand that through debate with our staff.

H

Explaining change is not something that we do very well and we need to.

H

Investigate further.

H

But I didn't want us to go without for the benefit of people that are going to listen.

H

To this recording for the record, etc,, without just drawing this out.

H

We'll bring it to the regulatory governance committee in October for a.

H

Fuller challenge by the non-executive directors and there will be work taken.

H

Forward over October and November about how we respond to this, based on.

H

Conversations with staff across the organisation.

A

≫≫ Thank you David. Mike.

F

≫≫ Thank you,, chairman.

F

On, the Fit and Proper Person regulation, I will talk largely about how it.

F

Is working in NHS, Trusts and Foundation Trusts, because the.

F

Regulation came in in November 2014 there and it's only come in for other.

F

Providers from April 2015, it now applies to all organisations that we regulate.

F

I think the first and most important thing is to remind board members that the.

F

Onus is actually on the Trusts themselves to ensure their directors are.

F

Fit and proper people and our task is to assess whether they are doing that.

F

And we do that in two ways.

F

Firstly, through our inspection programme,, our comprehensive inspection programme and secondly, by responding to concerns.

F

So now, in our inspection programme, we always look at a sample of the HR files.

F

Of directors of the Trusts,, we check to see whether they have had DBS checks,.

F

For example,, whether they have actually taken out references and we.

F

Also interview the HR director and with that, also add some questions in for the.

F

Ceo and the Chair about how they are ensuring that their own directors are fit and proper people.

F

And I think at the start, back in November, December time when we.

F

Started doing this,, there were quite a lot of Trusts that, where their processes.

F

Were not that good and I think as time has gone on, we have seen.

F

Improvements in the processes that the Trusts are going through.

F

The second part, and the bit that's probably causing a lot more work, is.

F

Responding to concerns- and we have a panel which either I or one of my adept.

F

Chief inspectors, Ellen Armisted, chairs, with Rebecca Lloyd, Jones and Amanda.

F

Hollywell as the sort of continuity people on this panel, where we go through any.

F

Concerns that are raised with us. We have had a total of 68 individuals named by people outside the.

F

Organisation, who are these fit and proper people, a lot of them are historic,.

F

Sort of more than two years ago,, the large majority, but some are more recent.

F

The process we then go through is to say, is the person currently a director in.

F

The NHS in England, because that, the people to whom the regulation applies,.

F

So there have been some, I, think it's about 22 of the 68, where that was not.

F

The case, so we can't take it any further because they are not actually subject to the regulation.

F

The second question: we ask, is there reasonable supporting evidence of.

F

Serious mismanagement or misconduct, and so has the person who is raising the.

F

Concern given us that,, which could come, for example, through an.

F

Employment tribunal report or some other report that they are aware of so.

F

That we can say yes, that there is something that we need to follow up on here.

F

We then contact the individual to -- technically to seek their permission to go.

F

To the Trust,, even if they didn't give permission,, we could get past that and.

F

Contact the Trust and ask the Trust to respond.

F

The Trust,, if we are not happy with the response the Trust gives- and we don't.

F

Think it's in sufficient detail,. We can ask them to go back and look into this in.

F

More detail and we have done that.

F

And in some cases, Trusts- have initiated independent investigations, brought.

F

Outside people in to look at their processes and to look at whether.

F

Particular individuals may be fit and proper.

F

It's very difficult to assess impact with this whole regulation.

F

I think we can say that Trusts are now taking this seriously,. We see that.

F

Through the inspection, programme.

F

We believe that we are almost certainly having a deterrent effect through having.

F

This regulation,, it may deter people from applying for jobs,. How would we know.

F

That that is happening., It's, very, very difficult to know. That. It certainly may deter Trusts from employing people who would not be fit and proper.

F

There may also be occasions where people have left posts that are director.

F

Posts in order to be in posts, they are not subject to the Fit and Proper Person.

F

Regulation but it is difficult for us to assess that impact.

F

I can say to you I think it has had an impact, but so can the head of MI5 or.

F

Mi6 say they think they have stopped terrorist attacks,. How do we actually.

F

Know, we do or do not believe them on that.

F

So, that is by way of introduction, but very happy to take questions.

A

I

≫≫ It strikes me that one of the issues about this regulation and its.

I

Implementation, is actually around a conflict,, understandable conflict, but.

I

Almost incapable of resolution between the needs of confidentiality,, which are,.

I

Which is always explicit to what you just said and the need for explanation to the.

I

Public of what is going on,, what the basis for decisions is,, what the standard.

I

Of, for instance,, serious misconduct or serious mismanagement is and how we.

I

Know that whatever the standard is, is being applied consistently around Trusts.

I

And when I say we,, not only the CQC but the public and because inevitably,.

I

Any decision that's made is likely not to be agreed with by everybody,. There will.

I

Be fulmination from one source or the other and I wonder: do we probably need.

I

To keep under review how we and everybody else is able to explain to the.

I

Public, what is actually happening.

F

≫≫ Again,. We absolutely recognise that challenge, in certain cases, if somebody.

F

Was convicted or if there was clear evidence of credit card fraud or.

F

Something like that,, it becomes very easy., The much more difficult ones are when there's an allegation. That, say, of bullying.

F

And harassment and actually then saying, is there evidence if that leads.

F

Back to an individual. And, where there is that evidence,, then I think it's clear cut but very often,. There.

F

Hasn't been that evidence to put back to the Trust to say actually,. Clearly it is this individual.

F

Now, if there was that evidence,, we would pursue that very rigorously..

A

E

≫≫ I understand we are only one part of the system here and that's very.

E

Important to stress- and we are checking what Trusts are doing, rather than policing the individuals.

E

Do. We know whether anybody has actually been caught by this so to speak,.

E

By this system, it's,, you know,, we had a presentation from Umesh about bullying.

E

Cultures within the NHS, and he today and also last night, talked about how that.

E

Went up to board level.

E

So I understand deterrence is going to be difficult to measure, but it would be.

E

Surprising, if nobody was falling foul of this and I suppose as part of that,.

E

Are we getting a comprehensive evaluation of the kind we are all implying.

F

≫≫ One thing to say is that not all the cases that are coming to us have concluded.

F

And some of these take really quite sometime for us, then, to get the.

F

Evidence,, to put it to the Trust,, to hear the Trust's response.

F

So and obviously we have, going back to Robert's point about confidentiality,.

F

We have made the decision that until we found a Trust to be in breach,.

F

We wouldn't name the individuals, so it's quite difficult, to...

F

≫≫ Sorry, I'm, asking you a slightly different question,, which is whether we.

E

Know there are Trusts that have taken action that prevented somebody from.

E

Being in a post, they shouldn't be in,, it's slightly different, I know it's not.

E

Directly, our responsibility, but in understanding the impact of this,, that's.

E

Really,, we really need to do know that as well, without that,, we haven't got a.

E

Context against which we can judge our...

F

≫≫ We know there have been resignations from Trusts, which may.

F

Relate to this,, there have been suspensions in Trusts that may relate to.

F

This and probably do.

F

So from that point of view, yes,, we do,, but these are not people that we have.

F

Named because this happened without us having to say to the Trust, you are in.

F

Breach, and issue a warning notice.

I

≫≫ But do we,. We have no requirement I presume to be told by a.

I

Trust that it has taken action in accordance with this regulation and I.

I

Wonder if, unless we, through inspections or whatever, actually find.

I

Out how we are ever going to be in a position to tell the public what's.

I

Happening and I don't mean on an individual basis, but simply by way of the.

I

State of Care report to say well, this regulation is having an effect because.

I

We know that over a period of five years,, whatever it is, N number of people have.

I

Been dismissed, got rid,, resigned, or whatever, through this regulation.

F

≫≫ In an ideal world,. You think we ought to get that point, but even before.

F

That, has this had a preventive effect and has behaviour changed,, because.

F

That would be an even more powerful effect if we could see that there was.

F

Less bullying and harassment, because people now know they could be under scrutiny for it.

A

≫≫ I've got one question for Rebecca actually,, which I think connects with.

A

What Louis and Mike have said about Addenbrooke's.

A

In, the appendix at annex A,? It sets out some of the requirements for deciding.

A

Whether somebody is a fit and proper person, but there in paragraph 3,, 3D,.

A

Which says, effectively,? That "It applies to an individual who has been responsible,.

A

Contributed to or facilitated any serious misconduct or mismanagement.".

A

Now, it's clear from what Mike says and from the report,, but I have only read it.

A

Quickly, that there was mismanagement at Addenbrooke's.

A

So, the question for Rebecca is whether mismanagement, in the sense that we.

A

Found actually is part of our obligation to look at,. You know, whether a Trust.

A

Operates a Fit and Proper Person policy that is effective.

D

≫≫ I think this probably takes us back to Mike's earlier comment that for an.

D

Individual to be unfit,, you do have to have evidence that links back.

D

Specifically to that person, so I think in the well led domain more generally,.

D

You might have an outcome where you know. Perhaps a board has not been well.

D

Led generally or there's been a sort of overall outcome of mismanagement, but.

D

Then, to nail that on an individual person might be quite difficult, because you.

D

Would have to show what their individual contribution to that was.

D

So I think if we had a report that did point towards one person,, we might.

D

Conclude that it was worth pursuing the FPPR. But in some of the cases that we.

D

Have looked at,, we have actually concluded that the concern that's been.

D

Raised is perhaps better dealt with through another part of the fundamental standards.

D

So a concern might be genuinely concerned, but it might not actually take.

D

You to one person,, it might take you to a more general concern about safety or.

D

You might want to go and do a focus, inspection and come at it from another way.

A

≫≫ Okay, thank you. Kay.

D

≫≫ Can I ask what the potential impact on an individual is if they are,, if they.

D

Were found to be unfit, I mean, does it have a long, lasting impact on their career?.

D

Because I ask because I mean the Winterbourne situation, I think that the.

D

Director that oversaw that has actually been disqualified by the,. Is it the.

D

Companies House, so he can't be a director for five years or something,.

D

So you know, and I think that was very clear because there was real kind of.

D

Negligence and abuse there.

D

But, then thinking of Addenbrooke's and it seems to be accepted that there was.

D

Mismanagement and the chief exec has resigned, there's also a general feeling.

D

That he probably did his best and that he is well meaning and he is a decent chap,.

D

So you know,, if we were in theory, to find somebody an unfit director in those.

D

Circumstances,, if that was then going to impact on them throughout their career.

D

History, I think that would be really very, very detrimental..

D

I am not,. It would be helpful to understand that if you are found as an.

D

Unfit director, what the impact was and really to say that the bar does need to be.

D

Quite high really.

D

>> I certainly agree with you, I do think it is a very high bar.

D

And, of course, the finding that we would make was that the provider was in.

D

Breach of their duty,, so we don't find an individual person unfit as such.

D

However, I do think as soon as it's known the reason the place was in.

D

Breach because X director was not fit,, then that would be extremely serious for.

D

That person and I, although it's possible, to think about circumstances where you.

D

Might not be fit to hold one role, but you might be entirely suitable for another or.

D

You might not be --, you might be unfit in one period of time, but then you might.

D

Sort of be rehabilitated, but I actually think the personal consequences would.

D

Be probably just reputationally very difficult for someone,, so we certainly.

D

Wouldn't be treating any of this lightly or coming to any rash conclusions about someone.

H

≫≫ David. >>, Can I, just --, Mike, I know you want to come in, but just...

H

(Inaudible) the point about -- thanks.

H

Two or three things just to pull out and I will try pick up on that point, Sir Robert.

H

To your point about, would we know,, then I think there's two ways that potentially.

H

We could know, and I think should operate, to enable us to know.

H

One is that I think inspectors do not just inspect,. They carry a portfolio where they.

H

Are conducting a relationship with that portfolio, whether they are adult.

H

Social care,, primary medical care services or in hospital teams,, so I think.

H

There's that soft intelligence, that I'd expect us to pick up.

H

Second point, in hospitals,, certainly for chief executive level, appointments,.

H

Monitor and the TDA have a formal role in relation to those appointments and I.

H

Would expect through our relationship with them to know what's going on.

H

That's the first point about it.

H

Second point in relation to this issue: about can people be recycled,.

H

Historically, the conversation in the NHS is somebody is found not to have.

H

Succeeded, they then get moved and then two or three years later,. They.

H

Reappear in another guise.

H

And so I think Mike has already said about the risk that people reappear in.

H

Wales,, where we have got no jurisdiction,, and it is something we need.

H

To be alert, to,, people, reappearing and so I think we need to be wise to that.

H

Kay, to your point, I think the example that you quoted is a very interesting one.

H

Because the prosecution, in inverted commas, prosecution, there was not.

H

Under the powers that we have got, but we are under the company powers in relation to it and if I am right, I think that was the first time those powers have.

H

Been used in a care setting and I think it comes back to this point about the.

H

Importance of us working alongside others in relation to those powers being.

H

Used and being applied.

H

So I think some of this is not just about how we apply the regulation,.

H

I think Rebecca's point about. We are not running a register of people who are not.

H

Fit,, what we are doing is actually looking at whether the system is checking and.

H

In a sense, I think the Addenbrooke' -- I don't want to comment on the chief.

H

Executive's case at all,, but I thought it was very interesting at Addenbrooke's.

H

Where the Chair position herself in relation to is this organisation taking its.

H

Responsibilities seriously in relation to the report that we published.

H

Again that speaks to your point, Louis, about how do you measure the impact.

H

Of people behaving differently, as a consequence of a regulation being in.

H

Place, I think Mike referred to the two independent reports that have been.

H

Commissioned by chairs in relation to allegations within the Trust,, and we.

H

Know there's a suspension of a chief executive in another Trust.

H

My personal view, I can't prove it,. This is the MI5 point, is that that would not.

H

Have happened 12 months ago without this regulation.

H

We are into how do you prove a negative in a sense in relation to some.

H

Of this, so I think it is tricky, but it is a right question.

H

I think what we need to avoid is the only way to measure impact is how many.

H

Prosecutions we have made, as distinct from how do we measure people.

H

Behaving differently as a consequence of that.

H

You are the academic researcher,? How do you actually establish that case.

H

I think it's really difficult.

H

And. So what we are trying to do in this report is reach for evidence which, at the.

H

Minute is probably anecdotal, rather than it is based on a research quality.

H

Methodology of evidence, to say this is what we think the impact of changed.

H

Behaviour is taking place. The last thing, in terms of can people be recycled, is any chief executive that.

H

Leaves where there is a question about whether they have been successful or.

H

Not, and they then applied for a job elsewhere, as a chief executive,. It would.

H

Be for the Chair of that board to do the assessment about whether they have.

H

Got robust processes,, so it's not now what does a Trust that they are leaving.

H

Do in relation to it,, but if that person reapplies for another job somewhere.

H

Else within this jurisdiction,, what does that Trust do?.

H

So I think we shouldn't forget that this is a responsibility on Trust Chairs to.

H

Appoint directors, so that the spotlight would go to the place that is considering.

H

The application from somebody,, because we are not running a register where.

H

People have been struck off,, but it is for that new employer to assess whether.

H

They have done the appropriate due diligence about that individual and they.

H

Are the changes in behaviour that I think we are trying to assess in the work that we do.

H

Sorry,, it's a rather long-winded,, but it is this changed behaviour point.

F

≫≫ Can I come in on case point. Again.

F

We again have thought about this, a lot, where that bar might be in even though.

F

That we are not the ones that are setting it.

F

And. Of course we are not like the professional regulators,, GMC or LMC.

F

Where they have a range of different penalties,, if you like, that they can,.

F

Suspension for a year or erasure from the register for life,, we are not in that position.

F

I think the other point about mismanagement is that sometimes we.

F

Observe when we go into Trusts that individual people may have been.

F

Over-Promoted, to get to the point of being a director.

F

And so this might be a director of nursing,, it might be a medical director,.

F

It could be any of them that are actually not suited to being director of nursing.

F

Let's say in a very,, very large, organisation.

F

But might be capable of being a director in a much smaller organisation,.

F

Learn the trade there and then be able to take on things.

F

That is something again that when we say, have they mismanaged,, they.

F

Haven't done a very good job there, but they could do a good job with proper mentorship elsewhere.

F

And. My final point is that obviously our discussion has been largely about the.

F

Nhs bodies, I think the issue of people reappearing is going to be much more.

F

Challenging when it comes to smaller organisations,, whether that's.

F

Independent ambulances, in my case or adult social care,, where they may.

F

Appear,, maybe the same name,, but people won't necessarily remember a.

F

Name and a completely different organisational title and set up in a.

F

Different part of the country,, where our inspectors won't be aware of them.

F

So I think that's something that we have got to be aware of for the future.

F

≫≫ Can I just make one point?.

I

The test under D or someone who has mentioned D has to be high because.

I

It's,, my reading of that is that if someone came within that paragraph,, they could.

I

Never be a fit and proper person to be a director. So that's how serious serious is.

I

The sort of case that Mike has just been talking about, might possibly come within.

I

B, which is the person has to have the qualifications, competent skills and.

I

The experience and obviously the history might relate in a particular job for.

I

Instance, someone was over-promoted,, so they didn't at that time or perhaps a.

I

Little subsequently have the competence, but they could develop the competence.

I

By remediation, by training and so on.

I

So, there are definitely in this regulation, two different levels.

A

≫≫ That's very helpful.

A

I think now, Paul,. Could you take us onto the Duty of Candour where there's an.

A

Important sentence in your paper,, which is, "The CQC's role, is to oversee and.

A

Enforce the regulation in all sectors- and we do this through our comprehensive.

A

Inspections and by responding to any information of concern that we receive.".

A

So I suppose the key question for the board about this paper is how our.

A

Overseeing role is being carried out and what issues there are.

G

≫≫ Thank you.

G

By way of introduction on this,. The spirit of this regulation is about openness and.

G

Transparency and promoting that across all health and care, services.

G

It came out as a result of Robert's report, and so, although there is a lot of.

G

Technical definition to the legislation and regulation, that is the underlying.

G

Premise, that's important for us to be thoughtful about and something that.

G

Rebecca is very clear on as well.

G

So, the situation here is that it's been a live regulation in all sectors that we.

G

Regulate from April 2015.

G

In the run up to that,. There was quite a lot of discussion between providers and.

G

Ourselves as to what it meant both in terms of the spirit but understandably for.

G

Providers, the details of what it would take to comply with this,. This was a new.

G

Legal duty on providers, over and above the professional duties that existed on.

G

Certain professions and the contractual duties that existed before this around candour.

G

And one of the reasons we are bringing this, partly to answer your question,.

G

Michael, on what we are finding, how we are discharging our responsibilities, but.

G

Also, to highlight the sort of work that we want to do to further clarify, along with.

G

The Department of Health and others, this regulation.

G

And we took a conscious decision on the second part of that not to republish.

G

More and more guidance straightaway in the run up or immediately after April 2015, but rather to have individual conversations with providers as they.

G

Contacted us- and there were a lot of them.

G

There- have also been challenges and discussions with individual groups,.

G

Including AVMA and Peter Walsh, and that has led collectively to a view from.

G

The Department of Health that they will need to consult on whether any changes.

G

Are required to this regulation. So, the position we are on in terms of making sure that we are as clear as.

G

Possible with our inspectors,, with providers, with the public,, is to be part of.

G

That consultation, and also to be looking at whether we need to put out further.

G

Information which we think we will,, but we need to do that and again in a sensible way that doesn't act against the way in which the DH consultation is.

G

Being conducted.

G

But, then, to go on to the specifics, what we are learning.

G

There we have carried out an analysis of reports,. We are seeing that our.

G

Inspectors are looking into this across all sectors.

G

We see most frequently that the --- this is an issue that's raised in the hospital.

G

Sector,, but they all are sectors. We do see things that are either directly about.

G

The duty of candour or related to the spirit of it,, including complaints, handling,.

G

Communications and transparency.

G

We have got further work to do, for example, in the hospital sector, one of.

G

The things we want to do is test whether when we look at safety, incidents, do a.

G

Sampling of safety incidents,. We can then track back and understand whether.

G

They, when they met the threshold of being a notifiable incident,, whether the.

G

Individuals,, the patients were contacted and offered an apology in the way that.

G

The regulation sets out. So. We can test whether it's actually happening in practice.

G

To date. We haven't identified a breach against this regulation, to be clear about that.

G

But again, there is the point of the proving the negative that David has.

G

Mentioned, that doesn't mean that there hasn't been a deterrent effect or.

G

An increase in openness and transparency.

G

I am going to finish on the point that David often makes,. We all make quite a.

G

Lot, that we are one of five influences on care and there's a general move, I think.

G

Over the last few years, in light of the second Francis report, to increase.

G

Openness and candour and transparency.

G

So. We will play our part, but it does need to be in the understanding that it's also.

G

Something that provider boards, front line staff, commissioners and people.

G

Using services also pushing in the same direction.

A

≫≫ Thank you, Paul.

A

Have colleagues, any comments on the paper?.

D

≫≫ I mean: how would we know that there'd been a breach,? Do we want.

D

People to tell us that, in some ways they might not know, but do you know --, but.

D

Sometimes you still hear sort of examples of where people have.

D

Suffered, you know, poor care,, maybe harm, and they say oh well,, the Trusts.

D

Were defensive or they didn't apologise, or it wasn't a proper apology and I just.

D

Wondered to what extent that kind of feedback can and should impact into the.

D

Work we do,, but whilst accepting that it's not just about CQC,, it's obviously about.

D

Providers as well but what, at what point will we decide? There has been a breach.

D

Based on, say, patient feedback to us, directly?.

G

≫≫ If any of the chief inspectors want to comment on this as well.

G

Two ways, one is if people do come to us with information of concern about.

G

That, then, our inspectors can absolutely follow up on that, either.

G

Through comprehensive inspection or reactively.

G

The other is if,, as it mentions briefly in the paper, I want to trial this in hospitals,.

G

We can go back and look and see if there was clearly an incident, that would.

G

Have crossed the thresholds, does that actually lead to an apology and the other.

G

Things required by the regulation. Mike.

F

≫≫ I think there are several ways in which we can pick this up.

F

I think there will be probably be whistleblowers on the staff within the.

F

Hospital that may say, you know,. We have seen things that we consider.

F

Constitute moderate severe harm, but we don't think the patients were being told,.

F

So we will follow up on that. We'll, hear from patients and relatives.

F

I. Think one of the ways is if the patients or relative have got to the point of having.

F

To make a complaint and when we look at complaints- and we see that actually at.

F

The time of the incident, that wasn't recorded, that would trigger us to look further.

F

I think what Paul has described of us systemically looking at samples of.

F

Incidents, so I think there are two aspects to that.

F

First of all, are some incidents not being rated at the appropriate level of severity,.

F

So they are being rated as low harm, and/or no harm, when actually, that is incorrect.

F

And, so they should have been subject to duty of candour.

F

By, looking at a sample of those,, we may pick that up.

F

Equally. We can look at the sample of those that were rated as of appropriate.

F

Level of severity to see what process they went, through.

F

So I think there are a variety of different angles that we can come at this from.

A

E

≫≫ I still I'm afraid worry about the potentially bureaucratic development of.

E

This and I suppose you can just see how it could in the end, go wrong,. The letters.

E

Become formulaic, the apologies become sort of non-apologies,. You.

E

Know, sorry-you-were-harmed sort of apologies or fill in the nature of the harm.

E

Here: sort of, that you can just see how that might go.

E

So the eventual success of this will be when it produces not letters but actual.

E

Candour and so the evaluation that is talked about in this paper,, that's in the.

E

End what this will have to get and our understanding of how it's working will be.

E

About candour in the system, as opposed to letters sent and I just want to make.

E

Sure that we've got our eye on that,, otherwise, we'll end up counting the.

E

Letters and not really getting the point of the measure.

A

L

≫≫ To save Paul from having to cope with all the responses, I. Think that's a.

L

Really important point Louis and it's particularly an important point in adult.

L

Social care,, because the way that the regulation is written is very health.

L

Focused in terms of this is level of harm and moderate and severe harm,, which.

L

Healthcare, professional kind of determines etc,, etc.

L

And I think, what's really really important is the first point that Paul made, which is.

L

This is all about creating a culture of awareness, openness,, a focus on safety.

L

And a responsiveness to people who are using services or their families and.

L

Carers when things go wrong, and particularly for us in adult social care,,.

L

Things go wrong and they will do just as Umesh said to us earlier,. We are talking.

L

About a people business in the sense of you know lots of people providing that.

L

Service, lots of people using that service, things will go wrong and it's the,. It's how.

L

We respond to that and an awful lot of what goes wrong in adult social care.

L

Won't reach this threshold,, but I'd be just as expecting of a level of candour and.

L

Responsiveness on behalf of staff and service providers for any of those things.

L

That are going wrong., So I think it's about the kind of expectations that we set and it.

L

Particularly comes through in the questions that we are asking when we.

L

Are looking at whether a service is well led.

L

And, when we are asking whether a service is well led,, we are asking about.

L

How inclusive the culture is,, how transparent it is,? How open it is,, how it.

L

Does respond to complaints and how it engages, for example, in a care home.

L

With relatives and other visitors who may be coming into the home and able.

L

To proffer views and insights to the way the service is run so that it's not just, I.

L

Am completely in agreement with you,, it's not just at that upper level end that.

L

We find of are looking at it, that we are trying to inculcate this as a culture with.

L

The values and behaviours that we heard so powerfully from Andrew and Umesh earlier.

L

So, that's the broader point and then the specific I think is that if and when.

L

We are on inspections,, we come across those issues,. That I think we should be.

L

Pursuing that and we should be making sure that our staff are capable and.

L

Confident of looking at it in respect of this particular regulation.

L

And that if people are raising issues with us, and the threshold, is being met and.

L

We don't think that people have been responding. Appropriately,, then again, we.

L

Should be pursuing that and with support from Rebecca and her.

L

Colleagues in legal services., But I think it's kind of we have got to do it in that tiered approach and not just.

L

Kind of say it's all about these really awful circumstances where people.

L

Absolutely should be doing the right thing,. They have got to be doing the right.

L

Thing, you know, throughout.

A

I

≫≫ Very briefly. I agree entirely with Louis that we have got to be really careful,. Everybody has to.

I

Be really careful, this doesn't just become a bureaucratic exercise,. In fact,.

I

It mustn't become a bureaucratic exercise at all so far as the patients and.

I

Service users are concerned..

I

It just leads me to a question really to our inspectors, which is when we are.

I

Thinking about the implementation of the duty of candour,, are we doing anything.

I

Which allows us to get feedback from those who have either benefited or not.

I

Benefited in terms of the patient service users from its exercise; in other words,.

I

What effect it's had for them,, good or bad.

I

Because, obviously, candour can be delivered in a way which is actually quite.

I

Distressing or helpful or somewhere in between the two and I think there's.

I

Potentially, some learning to be had about that which would be useful to.

I

Share,, if we can get the information.

F

≫≫ I think that's a really good point and it's not something we have done at the.

F

Moment but I'd also partly put it back to Trusts,. Are they finding out about it and.

F

We can certainly ask them what they are doing and then we can look at good practice is, and we can no doubt find there are some Trusts who are doing.

F

That and doing it well and others can then learn from it. As we have heard, earlier.

A

≫≫ Good. Thank you everybody. We, now come to Louis' report on regulatory governance.

A

I sort of do have a question, I thought it was an excellent document.

A

I do have a question for Louis, something he raised earlier, which is this.

A

Idea of the frayed rope because -- or the fraying rope.

A

Having been on a couple of inspections: now, I think this is a really difficult issue,.

A

Because if you look at the response of Addenbrooke's to the maternity.

A

Complaint, the Chair pointed out there hasn't been a maternal death in labour.

A

In the last seven years,, it's a tertiary centre for foetal medicine, and a variety.

A

Of points to try and say that maternity at the Rosie hospital is absolutely safe,, so.

A

I think as part of regulatory governance,, it will be very interesting to understand.

A

How you spot a frayed rope and at what point the frayed rope actually should end.

A

Up affecting our judgment about safety.

A

But Louis, over to you.

E

≫≫ There are several PhD theses on that issue: I suspect.

E

So we've had two meetings since I became interim chair,, one was I.

E

Reported back on very briefly last time,, so that was on social care,, Andrea and.

E

Her team came and talked about their inspection processes and last night,.

E

We had a primary medical, services, Steve and his team.

E

And I am just,. There's a paper on that one,. It would be tabled. Today.

E

Just, to summarise a couple of issues.

E

Both meetings were concerned about what we have already talked about today.

E

Which is the inspection trajectory but it, I? Don't want to go over all that again,. We.

E

Talked about it fully,, except to say that we seem to be -- without formally saying.

E

So, we seem to be agreeing a principle that is in the end. This would not become.

E

A numbers game. And that it would not, we would not be driving the numbers of inspections,.

E

Cqc would not drive its inspection numbers at the expense of the quality,.

E

The depths or the health and well-being of staff.

E

Those things would be more important.

E

Second thing is that I think this detailed examination of what is happening in.

E

Inspections has been really valuable for precisely the reason you are getting at.

E

Michael,, which is it allowed us, not just talk about what happens now, but to.

E

Think more about where we are going in the future,. How are we going to use,.

E

What are the fraying ropes,? What are the things we'll have to apply in the future.

E

When we get into phase two, our next,, the next phase of inspections and have.

E

To decide on priorities or decide on streamlining the methodology and so on.

E

And then I think beginning that discussion has been really, really helpful.

E

And then, the third thing is that --, but it's only a beginning, I should say, I haven't really got an answer to your question, except to say that's where that discussion has been taking place.

E

And. The third thing is that it's just how revealing it has been for both teams to.

E

Bring along inspectors and inspection teams to talk about the work.

E

And, if only there were a way in which people outside who criticise CQC and its.

E

Methods could hear the careful way that inspectors go about their work,. The.

E

Detailed examination,, the careful use of evidence, the questioning that they go.

E

Through, and all the chances that they give services to do something, to put.

E

Right the things that they are finding before eventually, enforcement action is.

E

Ratcheted up, I think people would be very reassured by the considered way.

E

That people are going about that. And, so there is a story to tell here about CQC's work, which I hope we will at.

E

Some stage get to,, maybe the State of Care report will give me an opportunity for that.

E

It's, a story about that care, that carefulness and also the beginnings of.

E

Improvement in services which were going wrong in some ways,, which were.

E

Failing and which people knew were failing.

E

Either, the people in them knew they were failing and couldn't somehow get out of the cycle or other colleagues, that sense of they. Knew, people knew what.

E

Was going on here and yet nothing was happening about it and then CQC come.

E

In and there's the beginning of an improvement trajectory, getting that.

E

Message out, which comes through very strongly when you talk to individual.

E

Inspectors about their work, I think would be a key part of how we report back to the public.

A

L

≫≫ Just to follow up on that specific point, Louis.

L

Perhaps, partly inspired by our experience of coming to RGC,, we had.

L

One of our most recent external co-production meeting, which is with a.

L

Mixture of providers, trade associations,, our experts by experience, other national.

L

Partners and commissioners.

L

We went through a whole day's worth of looking at the various stages of the.

L

Inspection process, had an inspector manager talking through various aspects.

L

Of it,, we did a couple of videos with a service that had gone through an.

L

Inspection recently with the registered manager and giving feedback on the process.

L

And, that was partly for the purpose that you described, which is about making.

L

Sure that people really understanding what we are doing.

L

But, also for looking at what is it that we can improve at the moment,? What do we.

L

Need to feed into the oncoming strategy.

L

But, it was everybody's collective view by the end of the day that actually the.

L

Material that we had used to create that day could be very powerfully kind of.

L

Wrapped up into a wee package, which we could make available publicly for a.

L

Variety of groups,, both people who are using the services and people who.

L

Speak on their behalf and carers, but also providers, I mean I was thinking the.

L

Perfect thing for people to use for their registered managers to say this is.

L

What's actually happening.

L

So, we are actively with Paul's teams in engagement, actively looking at what we.

L

Can do with that, so that we can create something that other people can use.

L

And we can kind of share that message a little bit more widely.

L

So, just to reassure you that we are thinking of how we can do that.

A

≫≫ Thank you very much, I'd, like to echo both what Louis and Andrea have.

A

Said, I think we ask inspectors to make extremely difficult judgments and you.

A

Know, I have been -- on the inspections. I have been to recently,, I have been so.

A

Impressed by the standards they hold themselves, to.

A

I wouldn't like to take some of these decisions.

A

I mean they are, you know,. Some of them are really very borderline, but we.

A

Ask our inspectors to take them.

A

And as I say, I have been, I can't -- I, don't think I could have been more.

A

Impressed by the care that, on the whole,, these decisions, with which these.

A

Decisions are taken. So. Thank you very much for the RGC report.

A

We have now got an opportunity for our guests to ask any questions that are on their mind.

M

≫≫ My name is David Hogarth and I'm. The co-ordinator of a small charity in.

M

Northwest London called Neighbour Care St, John's, Wood and Meadowvale,.

M

What we do is befriending and I do some befriending myself, I befriend, an elderly.

M

Man, a care home in northwest London,, he has dementia,, it is a care home.

M

Which has recently inspected by the adult social care directorate,, they gave it.

M

Five green ticks, including in the caring domain.

M

Nonetheless, I had some concerns and I put in an audio recording device.

M

When I listened to it, I was pretty clear that there was quite a lot of.

M

Unacceptable behaviour from the staff on it so I brought it to the Care Quality.

M

Commission, who acted very promptly on it and they agreed that it wasn't.

M

Acceptable and I took it to the local safeguarding team.

M

And there was a meeting early in September about this.

M

I and the next-of-kin were very keen that we should, surveillance would continue.

M

So that we could see that the care had improved and we thought that at the.

M

Meeting where the manager would be present, that we could use the fact that.

M

The Care Quality Commission and the local safeguarding team were there,.

M

To put pressure on him to agree because he hadn't agreed to have a camera or an.

M

Audio device afterwards.

M

However,, when we tried this,, we found that the exact opposite happened.

M

The safeguarding team said that we shouldn't, I shouldn't even have put in.

M

The original device, because of protection of the man's privacy --, the.

M

Next-Of-Kin said he didn't really care about his privacy,. He just wanted to be.

M

Treated compassionately.

M

I asked the CQC representative there how,. If we did this, how she would be.

M

Able to monitor the care he was going to receive and she seemed to say well,. She.

M

Said we do observing but I said: do you do it at two o'clock in the morning.

M

She said, she looked at care records,, mainly she said well, we'll talk to the management.

M

Well, I don't think the management are dishonest, but they are not there at two.

M

O'clock in the morning- and they haven't got cameras either,. How do they know what is going? On., So I found this in a very depressing -- and I began to see why people.

M

Sometimes go to the media with these things, rather than the Care Quality Commission.

M

However, I was pleased to see in your report, Louis, that one of the questions.

M

You had been raising was the caring domain, because it's very important in.

M

The adult social care area.

M

That is perhaps one of the most important domains that there are.

M

And I was wondering if you could possibly tell us a little about. Is there any.

M

Hope of getting some kind of reliance on surveillance from the CQC, because.

M

Andrea after the Old Deanery thing was saying there are limits to what the.

M

Cqc can know and of course there are,, but you should at least know everything.

M

You possibly can know.

M

And with cameras and so forth out there as available,. It seems to me that you.

M

Ought to be using them too.

M

I've got to write an article for the Caring Times, I am in the middle of it at.

M

The moment, I very much want to say something: positive.

M

Can you help me to do so?.

E

≫≫ In the end I think it's probably a question for you. Andrea.

E

As you know, David, I, am probably more in favour of cameras than a lot of people.

E

So I've a lot of sympathy for what you have got to say.

E

The point about caring that was made at the RGC, I didn't specify it today.

E

Although I did talk about it at the last board, meeting, was that it did seem an.

E

Unfeasibly large number of sites were being rated very positively on caring and.

E

Yet the number of reports that we hear suggested that may not be the whole.

E

Story is quite large and I think we have to be able to square that and in the end,.

E

We have to reassess how we rate caring and what evidence we have behind it.

E

I suppose that's the point. You are getting at,. What evidence do we have and have.

E

We gone as far as we can in getting it?.

E

When I said that these discussions have allowed us to think about the next.

E

Phase,, that's the kind of thing I have in mind.

E

I think we do have to look at a rating which everybody is doing well on and.

E

Ask whether it's discriminating enough and whether we have got the real evidence of what people's experience is.

E

L

≫≫ Thank you,, David, and you,, as you know, you both have written to me and I.

L

Have responded to the issues that you have raised.

L

And I think that in the particular circumstance, there was a good.

L

Response from the provider to the concerns that were raised, action was.

L

Taken and measures put in place to support appropriate care for the.

L

Gentleman who you befriended.

L

And I'm sure that he and his family are very appreciative of that and I think they.

L

Are very lucky to have you., But I think the responsibility for the CQC around this is, there's two levels: really.

L

One is what do we do when information comes to us about a concern and how.

L

Do we respond to that?, And I? Think the absolutely critical thing is that we need to make sure that the.

L

People who are directly responsible for providing the care and providing the.

L

Support take responsibility and are accountable for the actions that are.

L

Needed to be taken to sort the problem, out.

L

And that I think is what has happened in this case and I. Think we assisted in that.

L

Process, and the provider is very well aware of the issues, has dealt with it.

L

And is also well aware that we will be keeping an eye on that as time goes, on.

L

The second issue is more on the general policy perspective.

L

We know because we have been around it and at this table and Louis quite rightly says,. There is a range of opinions about the use of cameras and.

L

The use of surveillance in terms of assessing the care that is being provided.

L

We have provided information both for people who are running services and.

L

Also for people who are using services and their carers and families about the.

L

Considerations that need to be taken into account when considering the use of surveillance.

L

And actually I think in particular, the information that we have provided for.

L

People who are running services actually provide a really good framework for.

L

Them to think about how they do this, the proportionate use of that, the issues.

L

They need to take into account and ensuring that they don't just rely upon.

L

Surveillance as the way to ensure that their staff are delivering care in the right.

L

And appropriate way. Because much as people criticise us as inspectors coming along after the event,.

L

A camera is after the event,. What we really need to be making sure is that we.

L

Are employing the right people with the right values and behaviours, that there's.

L

Enough of them to be able to provide the care that is required and that they.

L

Are well led,, well, supported, have appropriate training and they deliver the.

L

Care that you and I would expect for ourselves or anybody else that we loved.

L

And cameras or audio surveillance or anything else, may well be an added.

L

Bonus in terms of the some of the things that people will do and lots of services.

L

Are considering that at the moment, but I think we need to actually get things right to start off. With.

L

And, finally, on the question about assessing caring, and Louis and I.

L

Discussed this at the committee a few months ago,, we do pick up on poor caring.

L

So there are inadequate,, we have rated some services as inadequate for caring.

L

And I know that when we have rated services as inadequate for caring or.

L

Requires improvement, that that,, those are places that we have.

L

Got really serious concerns about and we need to be looking into them.

L

I think that we have --. Of course, we are not there. All the time.

L

And I, don't think anybody can expect an inspection or a regulatory system to.

L

Know absolutely everything that's happening. Every minute of the day.

L

We need to make sure that all other influences on the quality of services are.

L

Playing their part as well.

L

And I think that that, the expectations we are setting for providers of service.

L

And what commissioners do locally, the amount of funding? That's available,, all of.

L

Those things,, including what staff do, need to be taken into consideration.

L

And, so it's not just us kind of looking at caring,, it's a collective responsibility to do. That.

L

I think that in general, we have some amazing staff working in social care,.

L

Who are absolutely dedicated and committed to doing the right thing, but I.

L

Said over summer,, some of them are doing it. Despite the system,, some of.

L

Them are actually doing. -- are caring, and demonstrating that to our inspectors.

L

And indeed, to the people who are using the services,, their relatives and carers.

L

But, they are doing that sometimes in a system. That's not valuing them,. That's.

L

Not supporting them and may well lead to some of the problems you have.

L

Mentioned, Louis,, and so that's the reason why all five questions are really.

L

Important and the reason why the very thorough look that we are doing through.

L

Our comprehensive inspections is something that we absolutely have to.

L

Continue to do and make sure, as we complete our comprehensive rating.

L

Inspection programme, that we deliver on that, so that people can be assured of.

L

The answers to all of those questions in services,, not just that specific one.

A

≫≫ Thank, you very much. Do. We have any other questions?.

I

≫≫ Thank you, chairman,, two brief questions: if I may, one relates to Trusts.

I

That are in special measures.

I

To, what extent,, if any,, does the lead? Commissioner CCG bear a responsibility.

I

For issues that have been shown up during the inspection and in the.

I

Subsequent support that is given to Trust?.

F

≫≫ Thank, you very much. A, very important, question. And. We are obviously commenting on the care that we find and that could be.

F

Due to deficiencies at the provider end or in the commissioning end, and that is.

F

One of the reasons why we hold a quality summit following our inspections.

F

When the report is available to the commissioners, to the Trust, to Monitor.

F

And TDA, and to the Local Healthwatch; a whole range of different stakeholders.

F

And, it is often apparent from that that there may be a problem with the.

F

Commissioning- and we have had Trusts say to us- we have achieved more in 40.

F

Minutes through one of these meetings than we had in the previous four years.

F

And, so let me give an example from mental health.

F

If, a very large Trust covering a whole county, large county,, does not have a.

F

Psychiatric intensive care unit,. We will comment that patients are having to.

F

Travel a very long way to get to a psychiatric intensive care, unit.

F

That may well be because the commissioner has not commissioned.

F

That but that will then be discussed at the quality summit.

A

≫≫ I think you said you had two questions.

I

≫≫ Yes. Thank, you,, chairman.

I

The second question relates to data and how members of the public can obtain.

I

Data from the Commission.

I

I have tried to obtain information about the aggregated percentages for each of.

I

The ratings across the three fields,, that is to say, 12 pieces of data.

I

I have tried to access that through the website, through the call centre and.

I

Through a data request.

I

And I have failed so far.

I

How, should a member of the public get this data?.

A

≫≫ Paul, I think as it happens, this data is going to be published in the State of.

A

Care Report, so, which is coming out in the next, you know, two or three weeks.

A

G

≫≫ That's absolutely right and we will have the data cut by our sectors.

G

The website does allow people to download some data, but, as you say, not.

G

In the level of detail that you are looking at so it is possible, for example,. If you.

G

Wish to see all the general practices over the last three months that have been.

G

Rated good, that's immediately downloadable as a spreadsheet, along.

G

With their locations and other sort of data., What we are looking at is how we can make that data in more granular detail.

G

More available to people,, it's part of the systems review that we are doing so. The.

G

Data we hold in our core systems is easily accessible,, where it's not.

G

Obviously not confidential data, available to members of the public and also providers, so they can look at things as well.

A

≫≫ Thank you.

I

≫≫ Thank you. That would be very welcome, I think, to members of the public and patient groups in particular.

A

≫≫ Good., Well I think that's our questions from our guests or the public.

A

I think we can now, unless there is any other business, close the board meeting.

A

We are slightly early and I think we should take advantage of that.

A

We are going to have, I think we should still have the 30 minutes for lunch, but.

A

We can reassemble if we can at 12.15 when we are going to have a.

A

Demonstration of a new piece of technology, the board is going to be able.

A

To use in future to access board papers.

A

So, thank you very much for this morning and as I say,, we'll reassemble at 12.15..

A

Okay, well, the lunch may or may not be there, but if it's not, it's on its way.

A

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