Reports & recommendations

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.
Such a programme of work should involve patients and the Patient and Client Council (PCC) as well as senior leaders and Trust Board members. It should include both an agreed strategy and prioritised implementation. Leadership for the plan should be clear. It should be overseen both at Trust Board and at regional level by the Department. The programme should include work on how to involve and support vulnerable groups and is likely to benefit from a learning partnership type of approach.
The programme should also include:
• A mandate to write directly to patients so that they are fully involved as partners in their own care.
• Directions regarding the framing and style of all communications with patients and families.
• Further work on the most effective way of involving patients and families in the framework for managing incidents and in the complaints process, taking account of the most recent policies in this area. This should include an agreement on whether to legislate for formal patient advocacy as recommended by the PCC, or whether an alternative effective approach is sufficient.
• A plan for how best to ensure a smoother system for responding to patients about day-to-day queries, concerns and issues with services. The aim should be both to provide relevant and necessary information to patients and to enable resolution of matters at an early stage, before formal complaints are raised. This should also include work on how best to communicate with patients on waiting lists, so they are not left unaware of their place on the waiting list and have clarity about what to do should their condition deteriorate. There should be a system to record harm to patients as a result of very long waits, so that this can be automatically highlighted to clinicians, managers, leaders and patients.
• An agreed plan to outline how to involve patients in improvement work and learning from error as well as in strategic planning of services.
• Guidance on the most useful way of capturing patient experience information.
• Guidance on the best way to provide information on quality, safety and patient outcomes in the public domain in a way that is accessible to patients and families.

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 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.

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.