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Professor R EndacottProfessor R SheaffProfessor R Jones
Dr V Woodward
BackgroundFrom 1990’s, UK gov advocate the ‘public
firm’ model for public service providersNHS services are managed through a
distinctive Board membership & structurePre 2003, 2 types of Trust – acute and
primary carePost 2003: introduction of Foundation Trusts
operate under licence (independant regulator Monitor)
more accountable to local populationsless central control
NHS Trust Board
NHS Bodies
Clinical services
clinical issues to influence management decisions
Performance managementContestability
lead
ership
Previous studiesGreater clinical focus at NHS Trust Board
level will improve the range, quality or cost of clinical care (Davies et al 2000; Marshall et al 2003).
Nursing leaders in NHS Trusts often lack the skills, confidence and opportunity to ensure clinical and patient care issues are adequately discussed at board level (Burdett Trust for Nursing 2006).
Study Aims1. To refine methods for measuring the
concept of clinical focus2. To examine effects of Trust Board
membership on clinical focus3. To examine relationships between
clinical focus and organisational culture4. To examine relationships between
clinical focus and service outcomes
Design To meet aims 1 & 2, two phase designPhase 1: analysis of publicly available data
(board meeting minutes, biographies of Board members)
Phase 2: observation at Board meetings for at least 3 sequential meetings
Phase 1 was preceded by extensive work testing measurement of clinical focus
Contextual dataSteering Group – Directors/senior clinicians Different processes for clinical issues getting
to BoardTrend towards greater part of meetings closed
to the publicExtent of clinical discussion influenced by
major events eg C Diff outbreak
Measuring clinical focus2 major judgments:
what constitutes an ‘item’how to distinguish clinical from non-
clinical in a replicable manner
An item.. a discrete issue or topic raised by a Board member. It is defined by content: - a relatively clearly bounded content,- distinct from preceding and subsequent contents of discussion.
Defining ‘clinical’ items...concerning the direct provision to patients of physical or psychological care or diagnoses (not the organisation thereof).
Coding manual developed
Clinical Non clinical
Service design and standards
General board processes
Clinical ethics and governance
NHS Agenda
Clinical outcomes Finance
Referral rates and volume Organisational
Activity Staffing
Evidence based models Patient Feedback
Validity & Reliability Piloted through observation of Board
meeting and review of minutes (n=5 Trusts) - 2 clinical academics, 2 academics
Inter-rater reliability: signs of ‘rater fatigue’: unusually small number of codes per pageover-arching trends that occur constantly recurring categories in large
section of textMedian agreement across 25 sets of minutes
= 95.35%
Population and Sample In Feb 2008, 298 Trusts listed on Department of
Health or Monitor websites:150 Primary Care Trusts (PCTs)92 acute non-Foundation Trusts (non-FT acute)56 acute Foundation Trusts (FT)Goal: 35 sets of mins/type of Trust = 105Sample: 2 difficultiesAvailability of minutesAccessibility of minutes
Sample - availability
1. One additional FT had minutes available but >9 months old
Significant - Chi-Square 1.548, p=<0.0001
Type Websites randomly selected
Recent 1
minutes downloaded
% recent minutes not available
FT 56 35 36.4
Acute non-FT
38 35 7.9
PCT 38 35 7.9
Sample - accessibilityPCT and acute non-FTs:8.6% (6/70) required ‘search’ facility91.4% (64/70) accessed via max 4 menusMajority located in ‘About us’ sectionAcute FTsAll 56 sampled to reach sample size (35)51% (18/35) accessed via max 4 menusSome stated minutes could be obtained via
‘FoI’ Act, for which a charge may be levied.
Early resultsMean no of items(range)
Mean % clinical items (range)
Foundation Trust 36.8 (18-64) 12.91 (5.5 – 24)
Acute Trust 58.8 (30-100) 15.54 (3.6 - 38.7)
PCT 64.9 (52-90) 20.4 (6 .0 – 47.8)
Ethical challengesAccess to private part of Board meetings
– requires all Board members to consentLengthy process – personal introductionsOne outright refusal from Board Chair –
no reason given
Conclusions Significant difference in availability and
accessibility of Board minutes between Foundation/non-Foundation Trusts
Trends in data to date: Fewer items identified in FT minutesLower % of clinical items in FT minutes
Steering group input essential to understand context
Next stages …Survey of Board membersTeam Climate InventoryAnalysis of publicly available service outcome
dataExamination of relationships between
Board membership, Clinical focus, Organisational culture and Service outcomes