Red lights flashing for Welsh health managers

Hywel Roberts says the NHS across Wales should learn lessons from the communications breakdown at Betsi Cadwaladr

The report of the Joint Review of the Betsi Cadwaladr University Health Board by the Healthcare Inspectorate Wales and the Wales Audit Office, prompting the resignations of both the Chair and Chief Executive at the end of June, must be the most damning report on any organisation that I’ve ever seen. There are certainly lessons to be learnt by the organisation itself but this report must be acted upon to bring about wide scale changes to the way that all Health Boards in Wales operate.

The problems at the health board, which runs Ysbyty Gwynedd, Glan Clwyd and Wrexham Maelor hospitals, included a breakdown of the relationship between chairman Professor Merfyn Jones and chief executive Mary Burrows. This, said the report, had “fundamentally compromised” the leadership of the organisation. Other issues included:

  • Management failings, which are contributing to significant risks with hospital infections such as c.dificile being under-reported.
  • Big financial problems with the health board managing to avoid overspending sometimes only by delaying operations and letting waiting lists get longer.
  • Managers failed to plan ahead for big changes that are needed to hospital services with no clear plan for which services might be cut or reorganised.

I’m in complete agreement with these conclusions but I don’t think that the recommendations go far enough. There were failures to understand basic management principles, personnel management, quality management and the need for clear processes supported by documented procedures.  Yet, surprisingly nowhere in the report is there mention of the need for effective management training throughout the organisation. This is a serious failure.  Without such training none of the recommendations will be implemented effectively.

Amongst my responsibilities back in the 1970s was the delivery of management training for the health service based on the recommendations of the 1967 Salmond Report and I became a member of a body with the grand title, Health Service Management Training Advisory Board for Wales. There appears to be no similar body today. I’ve searched the NHS Wales website and found no mention of ‘management training’. On the face of it, there appears to be no management training going on within the NHS in Wales today. If this is the case it is an appalling lack of essential support for health service management.

There are examples throughout the Joint Report of inadequate, or an absence of, management structures, processes and documented procedures. I found a Health Inspectorate Wales Cleanliness Check at Ysbyty Gwynedd in 2008 which reported that “there were no documented nurse cleaning regimes in place and no documented domestic cleaning schedules”. Another Inspectorate Spot Check in March 2011 found the same situation. The management had done nothing to correct the inadequacies that had been brought to their attention.

In April 2012 the Aneurin Bevan Health Board was fined by the Information Commissioner’s Office for breaching the Data Protection Act. Its report stated that the Board had failed to take appropriate organisational measures such as having appropriate policies, procedures and training for staff.  I would have expected such a report to have set the alarm bells ringing loudly with the then Health Minister and her Department. I would have expected the Minister to have asked if this could mean there could be an absence of documented procedures in other aspects of this Health Board’s activities or in other Health Boards in Wales. However, no alarm bells were sounded. A clear flashing red light went unnoticed.  Let’s hope that this will not be the case with the Betsi Cadwaladr Report.

In many sections the Joint Report calls for the development of management structures, processes and procedures. But this approach will not be effective and will lead to isolated unconnected silos unless there is a ‘whole organisation’ approach. The only way to do this is to adopt the Business Excellence Model as the framework and start by undertaking a process mapping exercise for the whole organisation. Why is it that the approach is widely used in the business sector but seemingly ignored by the public sector – or, for that matter, by the Banks which also have no effective management systems?

The model is so simple showing leadership developing policies delivered through effective clear processes, supported by documented procedures, to achieve results. This would be monitored through effective internal systems auditing leading to continual improvement.

I’ve written to the Health Minister Mark Drakeford to ask that he ensures:

  1. All seven Health Boards in Wales learn lessons from the Betsi Cadwaladr Report by asking each one to assess itself against the recommendations and to send these self-assessments to the Health Department. This would enable the Department to produce a report quickly to give a picture of the overall position throughout Wales.
  1. The development and delivery of effective management training at all levels within Welsh Health Boards.
  1. All Health Boards in Wales start working towards the development of sound management systems through the development of effective processes supported by documented procedures.
  1. An independent external assessment of the Health Boards’ management systems. This could be through Health Inspectorate Wales or jointly with the Wales Audit Office provided both bodies have suitably qualified staff.
  1. Effective manpower planning for the health services in Wales in order to ensure a sufficient supply of appropriately qualified staff to meet the needs of our Health Services in the future.

In addition I’ve asked the Health Minister to:

  • Reconsider the decision to transfer responsibilities of the Ambulance Service to the Health Boards until they have demonstrated clearly, through the above measures, that they have effective management systems in place. It’s the Boards’ management failures to ensure the availability of hospital beds that is causing all those queues of ambulances outside the hospitals.
  • Consider renaming the Health Boards. The word ‘Board’ is used for both the organisation that delivers the service and also the governing body that governs the organisation. This seems to me to be a ludicrous situation that would be impossible to see in the commercial sector where there is an unique company name, while the term ‘Board’ is used for the Board of Directors who govern the company. I therefore suggest that the organisation should be called ‘Health Services’ such as the ‘Betsi Cadwaladr Health Service’. After all this is what they actually do; they deliver health services to us, the public. The term ‘Board’ would then correctly be used for the governing body.

I also find the use of the word ‘University’ in the title of some Health Boards very peculiar. For example, there is no institution called the ‘Betsi Cadwaladr University’. Yet the current name of the Health Board strongly suggests that there is such an institution. I realise that there are technical reasons for the use of the term but these are meaningless to the general public. I suggest that the word ‘University’ be dropped so as to simplify matters.

Hywel Roberts is a Chartered Statistician and a former Quality Management Systems Lead Auditor who has delivered accredited Lead Auditor training programmes. His consultancy and training experience includes work in Europe, India, Indonesia, Singapore, the USA and the UK. He also has experience as a Team Leader for the Wales Quality Award.

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