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NHS boards should challenge more to assure themselves

29th April 2009

The boards of NHS trusts and foundation trusts in England must be more challenging of the information they receive about the running of their hospitals, according to Taking it on Trust, a new study from the Audit Commission, published today (29th April).

The study examines how the boards of NHS trusts and foundation trusts assure themselves that internal controls are in place and operating effectively.

While hospitals have processes to guard against risks, the controls and assurances are often poorly defined. This makes it difficult for boards to be clear that the assurances they receive are sound, which is essential if they are to keep patients safe and achieve their objectives.

The new report follows recent investigations by the Healthcare Commission into Mid Staffordshire NHS Trust and Birmingham Children’s Hospital NHS Foundation Trusts, which found failures in governance arrangements.

The Audit Commission says there are significant gaps between the processes on paper and the rigour with which they are applied. There is much guidance in place, but as with the banking crisis in the UK, this report finds that NHS board members need to understand, question and assess risk on an informed and ongoing basis.

Steve Bundred, Chief Executive of the Audit Commission, said:

‘Our evidence suggests that, while processes are in place, many board members at NHS trusts and foundation trusts are not always getting the right information that is needed to go hand-in-hand with the critical nature of work in hospitals. The NHS has, in many cases, been run on trust. But those who are charged with running our hospitals must be more challenging of the information they are given and more sceptical in their approach.

‘Healthcare is inherently risky and complex, and assurance is not easy in the public or private sectors. To do their jobs properly, NHS board members must review their risk management arrangements so that they can be absolutely confident that their trust is providing high quality care by well-trained staff in a safe environment all of the time.’

Bill Moyes, Executive Chairman of Monitor said:
‘Monitor relies on boards to be the front line of regulation. For boards to do this requires them not only to have the right information, but also assurance that it is accurate, relevant and reliable. This report identifies some examples of good practice around assurance and systems to support high quality governance, and others where this is not the case. It does not aim to provide another checklist, or more guidance in an area where there is plenty, but rather to paint a picture as to what good assurance may look like. It also encourages boards to pose the question in what way do they assure themselves that this is the case.’

The report is based on a review of the existing guidance on assurance and risk management along with site visits to 15 NHS trusts and foundation trusts. In the worst cases, the study found that the assurance processes had become a paper chase, rather than a critical examination of the effectiveness of the trust’s internal controls and risk management arrangements.

The report found that:

  • board assurance processes are generally in place but must be rigorously applied;
  • board members are not always challenging enough; and
  • the data received by boards is not always relevant, timely or fit for purpose.

The report includes recommendations for the Department of Health, Monitor and the NHS Appointments Commission. Key recommendations for NHS trusts and foundation trusts include the need:

  • to review their risk management arrangements, including the way in which risks are reported to the board;
  • to review how they identify and evaluate potential sources of assurance;
  • for better use of internal audit and clinical audit to provide assurance to the board; and
  • for systematic data quality reviews.

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