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.