Urology Services Inquiry

The Inquiry recommends that the Trust and Department work together to ensure there is:
• A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care.
• Direct communication with patients as standard practice.
• More effective handling of concerns and complaints, with an emphasis on early resolution, learning and advocacy support.
• Routine collection and use of patient experience data and transparent public reporting of quality and outcomes in accessible formats.

The Inquiry recommends that:
• The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress.
• The Trust should continue and strengthen its organisational development work. This should be aligned to a clearly articulated commitment to a just, open and learning culture.
• To ensure that each staff member understands their role in patient safety and the meaning of an open and just culture, the Trust should develop a fully funded development programme for all staff, including clinical staff in training. The programme should address what specific leadership development is required for staff and specifically, how best to ensure alignment between professional groups. Medical staff benefit from bespoke development, as do nursing staff and operational staff but there is also benefit in training groups of staff together, especially in the context of advancing an understanding of shared aims, such as patient safety. This programme should ensure that all staff understand how this aligns with Trust processes, aims and objectives, and more widely with these same objectives at a regional level.
• Specific consideration should be given to what ongoing data would best support the oversight of work to prioritise safety, so that this can be openly measured and tracked. Regard should be had to suitable resources such as "A framework for safety measuring and monitoring".
• This programme should be supported and monitored by the Department with a view to using it as a model across Northern Ireland.

The Inquiry recommends:
• The Department implements and funds a bespoke, regional leadership development programme for Board members and senior leaders, co-designed with external expertise including specific training in patient safety. This will complement the recently updated Board Handbook which provides excellent guidance and, if used as intended, should provide the basis for an effective Board. Such a programme should be devised with input from Trusts and professional group leaders and be informed by the work of this and other inquiries.
The programme should:
o ensure that all staff have sufficient understanding of their role in patient safety and incident reporting. Any plan must ensure that they understand the overall aims of the health and social care system;
o ensure that each professional group is assisted as needed to develop their professional duties as individuals and also to understand how they must work together in multiprofessional teams to deliver shared aims and objectives. In practice this will require each profession to have training directly relevant to it and then for combined training with other professionals in the team;
o determine how those with leadership and management responsibility are developed to understand, develop and deliver their services as a management team at each level; and
o determine how the executive team and the Board is developed to fulfill their duties. This will require a consolidation and refresh of the leadership development programmes currently available.
• The Department should facilitate discussion and debate regarding the work done in the Trust as a result of its engagement with the External Reference Group (ERG) with a view to continuing this approach. We recommend that the discussion includes consideration of a partnership arrangement with an organisation who has successfully brought about a cultural change. This would provide the Trust with the benefit of a critical friend who could add value in a pragmatic way.
• The Trust should formulate an agreed approach to ongoing Board development for the future, including lessons from the Inquiry and the events that preceded it. This should include specific training in the field of patient safety, including best practice in this area for all Board members and senior managers.
• The Department should review current methodology for Board self-assessment and guidance on Board composition. Consideration ought to be given to greater clinical input and more service user feedback and representation on the Board.
• Each Trust should appoint a Senior Independent Director (SID) as is recommended by NHS England. A SID is a Non-Executive Director with enhanced responsibilities. The SID can function as a sounding board for Board members or others who feel they cannot raise issues through normal mechanisms. The SID provides support to the Board Chair, as required, but is a point of contact regarding any issues with the Board Chair.
• The Trust should devise its own programme of work to agree on how best to implement ongoing leadership development for all Board members and Trust senior managers. This should include clarification about how to link into specific leadership development for medical managers, or other professional groups. In addition, the connections with wider organisational development programmes and regional development programmes should be clearly described in a way that ensures that there is a clear alignment of purpose. The comments and recommendations of the Messenger Report are relevant to such a programme of work.

The Inquiry recommends a programme of work by the Trust to:
• Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get lost due to time pressure.
• Develop a comprehensive data and information strategy to support assurance, learning and decision-making.
• Streamline its governance forums to ensure that information presented leads to action and improvement.
A revised programme of work led by the Board and SMT at the Trust should include:
• Agreement regarding an ongoing way of assessing governance effectiveness.
• Identification of any current gaps in assurance.
• An agreed approach to developing a high-quality data and information function to use relevant and timely data to help manage and assure standards of care and drive decision making. This would not only shine a light on areas that need improvement but also on those areas where there is good assurance and standards are high.
• The Inquiry recommends the development of a data and information strategy with clear aims and ambitions to cover the provision of assurance and learning to improve. Such a strategy requires broad input and expertise. It could usefully encompass a specific focus on developing agreed patient safety and quality standards.
• There is a need to re-evaluate the weekly SMT governance meeting and consider how it could be streamlined. This meeting was set up to increase the oversight of key quality and safety issues and to share learning across directorates. The breadth and depth of information shared is significant, but the Inquiry considers that there could be clearer links between the audits, investigations shared at this meeting and agreed improvement initiatives. The idea of a need for a transformation manager came out of Trust learning from the Inquiry and the post was supported by the Board. As this role is advanced it could usefully help to bring initiatives together.
The opportunity presented by the relatively manageable region of Northern Ireland and the recently introduced patient record management system, 'encompass', provides a significant opportunity to develop a regional approach in this area. The Inquiry considers that:
• The Department should take the opportunity to develop a regional information strategy. In the meantime, Trusts should be supported to incrementally improve their information systems in a way that sustains governance and decision making generally across the system.
• The Department should consider how safety issues that cross organisational divides could be overseen in the future. For example, in the prescription of drugs.
• The Department and Trusts should agree where decisions can be made regarding the kind of data required to provide assurance or signal problems. This would allow appropriate safeguards to be put in place.

We recommend that:
• The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts in terms of making the best use of the new framework and training staff to understand it. Departmental regional support for this training would be helpful. This could take the form of multidisciplinary working groups where illustrative case studies could be used to demonstrate best practice and to discuss queries.
• There should be shared knowledge across Trusts and greater use of inter-Trust investigation leads and other mechanisms for sharing expertise.
• The emphasis of the new framework must be on rapid learning, patient involvement, and system-wide sharing of learning rather than blame.
• The Trust should use the platform provided by the Northern Ireland framework to refresh its approach to incident management. Areas for attention include the use of the current incident reporting system, the weekly incident meeting, and the clarification of responsibilities for completing the agreed learning and actions.
• The Trust should continue to improve Board oversight of SAIs and continue thematic reporting of incidents. This reporting should be further developed to ensure that Trust-wide programmes of improvement and transformation can be supported as needed.
• The Trust should continue to develop its approach to SAIs under the leadership of the Medical Director with input from senior managers in governance.
• The Trust should ensure all staff complete a mandatory programme of training that emphasises the primacy of patient safety, as well as learning from error in a way that can be understood and maintained by all staff. While clinical staff have a clear professional duty to report risks to safety, other staff need to understand they too have such a duty.

The Inquiry recommends that:
• There must be sustained investment in leadership development for doctors at all career stages. Improvements discussed in the Medical Management and Leadership chapter should continue. The Department should establish a dedicated regional programme to strengthen medical leadership and management. This programme should focus on all aspects of medical management and leadership; aid continuous development and provide opportunities for ongoing challenge.
• The Trust should continue to develop its medical managers and leaders ensuring that roles and responsibilities are clear and there is sufficient time allocated to perform the roles.
• Within the Trust there must also be access to ongoing training and development for all medical leaders. Leadership programmes for all doctors, medical managers and clinical leaders must be developed and sustained. Such programmes should be clearly linked to wider organisational development programmes to foster shared decision making across professional boundaries.
• The work done in relation to improving understanding of the different approaches to managing doctors in difficulty and the wider training on the MHPS framework put in place at the Trust should continue.
• While the MHPS framework exists in its current form, the Trust should consolidate the work undertaken to date and develop a protocol to address the recommendations listed at the end of the MHPS chapter.
• The work relating to redevelopment of the MHPS framework in Northern Ireland carried out by the Department should continue at pace as it is long overdue. The Inquiry endorses the recommendations made by the Department's review group, advocating a completely new approach to replace the MHPS framework.
• The Department should continue to invest in and enhance regional working groups for Medical Directors and other senior medical managers. These groups should provide expertise in relation to mechanisms for dealing with doctors in difficulty and difficult doctors. The groups can share case studies and best practice. The remit of these groups should include an emphasis on the use of external resources such as Practitioner Performance Advice (PPA), as well as how to develop and use robust internal processes. Such processes must encompass the need for any necessary support for practitioners, integrate with and link to all current processes that relate to how concerns about medical staff are addressed.
• All doctors and doctors in training need to be made aware of current processes and receive mandatory training in this area.
• Doctors must be involved in the management and leadership of services and in strategic planning for the future. There must be targeted funding and oversight from the Department. In the interim the Trust must ensure its medical staff is involved in the management and leadership of its services.

The impact of the Inquiry on the Urology Department has been very significant. The Inquiry recommends that the Urology Service be provided with ongoing specific medical and operational leadership support from Senior Management, the Board and the Department. This will allow for stabilisation and help to rebuild the confidence of patients, the public and staff. The Inquiry considers that using the Urology Service to test improvement initiatives, for example in the area of data and information, might be of benefit to the wider Trust. Moreover, it may help boost morale in the service by allowing it to present as a proactive high-quality service at the forefront of developments for urology services in Northern Ireland. The Inquiry recommends that in providing that support, senior management, the Board and Department should consider the following:
• The recruitment of a stable consultant workforce is a priority. The Department must develop a clear strategic plan for urology services at the Trust and in Northern Ireland more generally. The problems in recruitment in urology should be considered more broadly as part of the general problems with recruiting consultant medical staff in Northern Ireland. The Inquiry considers that there is merit in setting up a specific project relating to the recruitment and retention of medical staff as part of workforce planning functions in the Department. While we recognise that there are problems relating to this in many areas across the UK, some Trusts have been successful in recruiting and retaining the expertise required. Novel solutions tailored to the situation are required. The Department and Trust should learn from what has succeeded elsewhere.
• The urology team and medical leaders should be given the time and resource to continue to participate in and contribute to Northern Ireland wide working groups to develop plans for the delivery of services. This support should include the implementation of the Getting it Right First Time (GIRFT) review.
• Methods for communicating with patients on waiting lists should be tested in the Trust's Urology Service. A working group should be set up to advise on how the following areas can be addressed:
a. The new encompass system allows greater information to be provided to patients however patients require explanations and information that is not necessarily on the system. Possible ways of improving how patients can access information relating to appointments, investigations and procedures and/or access advice relating to their condition should be tested in urology before being rolled out across the Trust and regionally.
b. In addition, some patients may deteriorate and come to harm while on waiting lists. Methods of assessing and mitigating this through reprioritisation should be tested in the Urology Service at the Trust and then considered on a regional basis.
• Data sets of information for meetings should also be tested in the Urology Department alongside the improved support for audit already in place. This could then be used as a model for other services.

The Trust has worked through a detailed action plan relating to Cancer Services, specifically in relation to the oversight and support for MDTs and has addressed the issues identified in the SAIs in urology. Extending the work to include dimensions of quality, safety and strategic planning in Cancer Services would be of benefit. The Trust has understood the need for further improvements in the management and leadership of Cancer Services and has recently told the Inquiry that they have created a new senior manager role. This role includes overseeing safety and quality and bringing oversight of Cancer Services into a quarterly strategic Cancer Board. The Inquiry recommends that the Trust consolidates all current work into a project led by SMT to consider the following:
• Development of the medical leadership of Cancer Services at the Trust so that there is a more strategic view of the delivery of services for patients with cancer, including an emphasis on quality standards and strategic planning for the service.
• The Department and Trust should devise a programme to support the key role of nurses in cancer care and to develop senior cancer nurse leadership as part of the leadership team in Cancer Services. This should be done both at Trust level and regionally.
• Cancer Services should be led by a formal triumvirate comprising a senior manager, a doctor and a nurse who would share decisions. The Inquiry considers that this style of coordinated triumvirate leadership would be beneficial across the Trust. We recognise that nurses already make very significant contributions in leadership roles and could significantly enhance management structures. Development of this type of triumvirate of clinical leadership should be added to the overall project on medical management and leadership led by the Medical Director.
• To ensure that the Board is fully aware of the risks to quality care and plans to mitigate these, Board committees should receive regular reports on the service. These reports should bring operational performance, quality and strategy together to enable informed discussion.
• As the focus on Cancer Services came about because of the SAIs in urology related to patients with cancer, the urology service should be used to test new ways of bringing cancer data together. The data should be integrated in a way that would help staff and patients understand the overall quality of care being provided.