Analysis of Patient Harm and Inefficiency in Liverpool Community

The report on the Liverpool community health services headed by Dr Bill Kirkup CBE was a culmination of years-long complaints on management of NHS trusts in England. One critical aspect of service delivery revealed to have been severely breached was patient harm. It was a culmination of successive failures in management of health services centred on the inefficiency of Liverpool community health services NHS trust board. As this research shall demonstrate, the inefficiency of the trust board resulted to staff harm that went unnoticed by the relevant national oversight authorities. Eventually it meant that most instances of patient harm were overlooked or poorly remedied.

Patient harm is the opposite of patient safety. Essentially, patient harm is a direct consequence of lack of patient safety which is defined by the World Health Organization (WHO) as a health discipline which has emerged due to arising cases of harm occasioned by the complex development of health services (WHO, 2019). Aspden et al., 2004 defines patient safety as the “prevention of harm to the patients” thus the converse would mean that patient harm is the lack of safety to the patient.

The independent panel (2018) dedicated a whole chapter to the apparent and extensive cases of patient harm and especially its causes. Paragraph 3.3 of the report placed staff distress as the direct cause of many instances of patient harm. Yet the elephant in the house, according to the report, was the apparent inefficiency of the leadership and management class of the trust (Kirkup, 2018, pp.14). This demonstrates complete breakdown in the process of service delivery at the trust (Illustration 1 below).

To demonstrate the breakdown of the process, an analysis of the inquiry under chapter three reveals that the problem initiated at the trust board level which failed to conduct oversight in an effective manner often overlooking issues raised as the cause of patient harm. According to paragraph 3.6 of the report it suffices that problems highlighted to the board in 2013 would still suffice in 2015 thus showing that they were not addressed. The report highlights that even if actions were taken in some cases, they were not effective as they did not identify the actual root cause of the problem. Hence the process of implementing the actions ended up not reflecting on the patient safety outcome.

Whereas it appeared that the management led by the trust board were aware of the problems of patient harm, there was no alarm raised over the recurrence of these problems and no attempt to find out the deeper issues affecting the medical staff. The Liverpool community health objectives for 2017/2018, (Liverpool community health annual report and accounts 2017/2018, 2018) included the development of its staff to improve patient care yet the inquiry revealed deep-rooted issues on understaffing, lack of competent and skilled labour which would have been apparent if there was presence of proper management. The result was that patients ended up suffering pressure damage in some medical fields since the understaffing adversely affected the timely assessment of risks on patients (Kirkup, 2018, pp.16).

As illustrated under paragraph 3.16, whereas there were clear cases of poor recordkeeping in some departments, little was done by the management in terms of constant training or peer review to maintain quality services. Yet it is the expectation of any organisation to conduct numerous trainings on its staff based on the experiences in the field so as to ensure improved patient service by all staff.

Whereas every organization has its own unique culture, it is the expectation in the medical field that the leadership of the organization fosters staff engagement and cordial relationship between the management and the other staff so as to promote cooperation and openness. Yet the inquiry in Liverpool revealed that the staff worked under constant fear of open abuse and blame game. The toxic culture of arbitrary disciplinary proceedings and rude human resource department amounted to bullying of staff. To top it all, the management sought to reduce the human capital, which was already under-staffed and overburdened, even in the most critical departments. Effective health governance NHS policies were either neglected or ignored.

Whereas it is the requirement that health governance pays maximum attention to patient safety and improved care, the lack of persons with a clinical background in the Trust’s board meant that decisions were made majorly based on financial needs. Even though financial stability of a health institution is key, its overemphasis was at the expense of improved patient care thus resulting to patient harm. It appears that even from the annual objectives set by the Trust board for the financial year 2017/2018, there was deliberate intention to efficiently spend money and the directors’ report made no reference to attempting to balance use of funds and ensuring improved healthcare (Liverpool community health NHS Trust annual report and accounts 2017/2018, 2018, pp. 27).

The National Institute for Health and Care Excellence has set the guidelines and standards which are meant to be used for efficient organisational culture spearheaded by the management for the wellbeing of the organisation’s staff (NICE guideline, 2015). Guideline 1.6 tasks the senior leadership, which presumably is the Trust board, with the task of making sure that those in clinical governance support their staff and cooperate with them to ensure maximum mental health (NICE guideline, 2015, pp. 10). Yet it appears from the inquiry that the Trust board completely neglected that role by failing to consider key issues arising on staff wellbeing including bullying. Moreover, under NICE guideline 1.8, line managers who include human resource department are bound to ensure cooperation and communication between them and their staff so as to create conducive environment for the staff to deliver services to patients. Yet it is apparent that the line managers terribly failed on this as well.

On the other hand the Care Quality Commission’s 13 fundamental standards require that the provider of healthcare services must fulfil several criteria and among them is good governance, safety of the patient, proper staffers and handle patient complaints effectively. All these culminate to one benefit to the patient which is patient care and safety (Illustration 2). Yet the inquiry found out that whereas the Trust was receiving many complaints and compensation claims, it struggled to respond to those issues and take blame but rather transferred blame to its staffers and line managers (Kirkup, 2018).

Staff engagement

The most effective reform would be to create staff engagement. Staff engagement has been defined as the state of mind that compels or drives employees to be loyal to their organisation and to be wholly involved in their work (King’s Fund, 2017).

Staff engagement has numerous benefits to the eradication of patient harm. Indeed as West and Dawson (2012) connote, evidence suggests that when staff are more attached to their work, there is reduced patient mortality. They further suggest that staff engagement results to better financial performance for the organisation. According to BoardBrief (2010), patients become more loyal to the organisation and thus contribute to more finances.

When staff engagement is increased, it will result to staff feeling appreciated by their bosses hence resulting to better mental health wellbeing of the staff (Jones et al., 2015). In this case staff engagement would mean that the bullying culture would be eliminated. According to a 2012 research, when staff reported more bullying by fellow senior staffers patients also reported poor experiences at hospitals (King’s Fund, 2017).

Staff engagement would also help reduce instances of unnecessary absenteeism thus saving on costs for the Trust.

Trust Board composition

According to section 4 of the inquity report, it suffices that the board was mainly comprised of persons who were not conversant with the structures of the NHS. This is because mos of them were derived from the local community and later from within community health service but still their skills and experience was limited (Kirkup, 2018, pp. 41). Hence only the chairperson and the chief executive officer were conversant with the processes and the activities of the Trust. This means that control and oversight at board level was hampered since there was no one else to verify the presentations made to the board.

To remedy that, it would be paramount to include officials working within the Trust as line managers in the realm of executive directors of the Trust. Futhermore the continued ignorance of staff’s demands means that a union representative ought to be included in the governance of the Trust to air their grievances.

According to Pritchard and Hardy, 2014, less than 10% of all Trust boards have non-executive directors with clinical background and at least 48% of all boards having no director with clinical background. This means that decision making is largely based on business viability and financial performance as was the case in the Liverpool Community Health Trust which ended up creating policies to reduce workforce yet it was struggling with staff shortage.

Mannion et al., 2015, suggests that having doctors on the Trust boards may benefit the Trusts more and generate better outcome. For Mannion et al., 2015, this is ironical since the NHS since 1983 has been advocating for boards primarily ran by persons with a medical background. Their argument is galvanized by Veronesi, Kirkpatrick and Vallascas, 2013, whose study on Trusts in 2005 to 2006 and those found in 2008 to 2009 with doctors as directors performed better health care services overall. But those with nurses who had become to directors did not register similar results. However, Mannion et al., 2015 cautions that a rallying call to have doctors as directors of Trusts should not be a reason to increase the composition of the boards since there is evidence to suggest that a larger board may result to inability to make decisions resulting to inefficiency.

Having doctors on the Trust board of Liverpool community health, would help air issues of staff bullying and fear culture which even if the board would be unwilling to discuss, the regulatory authorities would still be aware of them and force for an explanation.

Developing organisational culture

Pursuant to section 3, paragraph 22 of the report, the panel accused the Trust of lacking a positive organisational culture which resulted to chaotic implementation of policies and flouting of basic guidelines by the human resource department and increased bullying of the staff.

The inquiry attributed the lack of culture to the fact that the Trust had been newly formed at a time when the NHS was being restructured. This recommendation would go hand in hand with staff engagement. According to the King’s Fund, 2014, leaders in the Trust are better placed to inculcate values in the policies of the Trust as a means of creating a culture of values and integrity and not one of abuse. Further, the King’s Fund, 2014, attributes blame attitude among the leaders when something goes wrong to negative culture which creates discord between management and the staff. Thus developing a robust organisational culture would facilitate the elimination of bullying culture resulting to better staff engagement thus reducing patient harm.

Quality self-assessment criteria

Due to lack of organisational culture, it is apparent that Liverpool community health Trust does not have a quality assurance standard. In other words, the staff did not have a set of objectives on the quality priorities that they wanted to achieve hence killing the spirit of self-drive. However, this is not a lone situation for Liverpool.

According to the King’s Fund authors Foot et al., 2014, whereas most community service workers have their own personal quality priorities (where patient harm features prominently) , there Is not much emphasis placed by the NHS on community health service hence quality priorities expectations are much lower or degraded than they deserve. This means that when community health services underperform there is not much scrutiny unlike in acute trusts. This might explain the reason why the Liverpool community health trust was never much scrutinised. Thus according to Foot et al., 2014, this resulted to lack of data or comparable standards across board and therefore setting quality indicators for community health trusts becomes a challenge.

Despite the low expectations on community health trusts, the fact that patient safety featured prominently as a quality priority means that establishing quality self-assessment standards and indicators may remedy the neglect of patient care.

Governance model and devolution of decision making

According to the report, the trust was accused of gross failure in clinical governance (Kirkup, 2018, pp. 22). The inquiry revealed that there were incidences which happened repeatedly yet the NHS perceives those incidences to be a so-called, “never events.” This point towards gross failure of clinical governance.

As the Liverpool community health service is geared towards a foundational trust, it is most likely that the structure of governance reserves too much decision-making power on the top organs and more so the board. The King’s Fund suggests that removing too much control from the top would help in creating a governed mutual model or employee-owned governance structure thus enabling faster decision making to avoid occurrences of “never event” patient harms. According to BroadBrief, failing to devolve decision making destroys collaboration between management and staff hence keeping vital issues below the focus of the board.

Implementation plan

According to BroadBrief, aligning interests of the organisation and that of clinicians empowers the staff and creates a sense of interdependency. This would then result in staff engagement and eventually grow into the organisation’s culture. Hence this research introduces an alignment implementation plan to take care of staff engagement and developing organisation’s culture.

Aims of the implementation plan

Foster staff engagement with management.

Develop a positive Liverpool community health NHS Trust culture.

Objectives

Create space for professional growth

Create policies touching on the desired values of the Trust

Involve the staff in decision making process

Enhancing patient safety through staff innovation

Eliminating bullying culture among staff

Advantages and disadvantages

One disadvantage is that implementation plan would require two financial years to fully manifest. However, its main advantage is that gradual implementation allows for monitoring of its impact. It is also very cost-efficient as it does not require incurring any additional cost in terms of budget allocation.

In conclusion, the Liverpool community health NHS Trust weakness was in the internal relationship within the trust hence resulting to unnecessary patient harm. The management needed reform and therefore it was paramount to have most changes coming from the top of the hierarchy for it to be efficient.

REFERENCES

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BoardBrief, 2010. Building Constructive Hospital/Medical Staff Relationships and Alignment. [pdf] BoardBrief

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King’s Fund, 2014. Improving NHS care by engaging staff and devolving decision-making: report of the review of staff engagement and empowerment in the NHS.[pdf] King’s Fund

Kirkup, B., 2018. Report of the Liverpool community health independent review. [pdf] National Health Service.

Liverpool Community Health NHS Trust, 2018. Liverpool community health annual report and accounts 2017/2018. [pdf] Liverpool Community Health NHS Trust

Mannion, R., Davies, H., Freeman, T., Millar, R., Jacobs, R. and Kasteridis, P., 2015. Overseeing oversight: governance of quality and safety by hospital boards in the English NHS. Journal of

National Institute for Health and Care Excellence, 2015. Workplace health: management practices. [pdf] National Institute for Health and Care Excellence. Available

Pritchard, C. and Hardy, J., 2014. An analysis of National Health Service Trust websites on the occupational backgrounds of non-executive directors’ on England’s acute trusts. JRSM Open.

Veronesi, G., Kirkpatrick, I. and Vallascas, F., 2013. Clinicians on board: what difference does it make? Social Sci Med : 77; pp.147–155

West, M.A. and Dawson, J.F., 2012. Employee Engagement and NHS Performance. [pdf] The King’s Fund

World Health Organization (WHO), 2019. Patient safety. WHO. Available at:

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