How To Govern An Health Service

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1 Clinical and Care Governance Mapping: Issues for nursing under the integration of health and social care 1. Introduction The RCN has defined clinical and care governance as a robust system for assuring high standards in the delivery of safe, personalised and effective health and social care services. Embedded from frontline staff to corporate boards, good care governance will define, drive and provide oversight of the culture, conditions, processes, accountabilities and authority to act of organisations and individuals delivering care. Clinical governance is one of four interdependent areas of governance for quality healthcare, which include: - Clinical governance - Financial governance - Staff governance - Information assurance Section 2 and 3 of this paper sets out the background to clinical care governance and maps the current structures, roles and responsibilities around delivering clinical care governance in health boards. Section 4 presents the issues and role that nursing, in particular the Executive Nurse Director, plays in effective clinical governance. Section 5 looks at the current proposals around clinical and care governance under the integration of health and social care, and finally Section 6 analyses the issues for nursing of the current proposals and the potential consequences to the care delivered for patients. There is a list of key definitions in Annex 1 and a timeline of developments in clinical governance across NHSScotland in Annex Background to clinical and care governance in NHSScotland 2.1. The introduction of clinical governance The concept of clinical governance was first introduced in the White Paper Designed to care: renewing the National Health Service in Scotland (1997) 1 as part of the Government s focus on the quality of services to patients being reflected in the 1 Department of Health Scottish Office (1997) Designed to care: renewing the National Health Service in Scotland V1.1 May

2 management structure of Trusts. Alongside the Health Act (1999), which introduced a statutory duty on health boards around clinical governance, the Scottish Executive issued a series of guidance to boards on the implementation of clinical governance in NHSScotland. The initial guidance in states that effective clinical governance will provide assurance that: quality of clinical care drives decision-making about the provision, organisation and management of services the planning and delivery of services take full account of the perspective of patient care delivered meets relevant standards unacceptable clinical practice will be detected and addressed patient and staff confidentiality and the right of clinical staff to exercise individual clinical judgement are not compromised The guidance is clear that clinical governance will form a complementary and equal strand alongside financial and probity issues in their accountability. The Chief Executive is responsible for the delivery of clinical governance and reporting to the Board. The guidance was issued before the unification of NHS Boards and before Nurse Directors and Medical Directors became full NHS Board members. However it still emphasises the role of Nurse Directors in implementing clinical governance and in providing professional advice and support: while Chief Executives have overall accountability, they will discharge this responsibility through the management structure of the Trust 3 and will look especially to the Medical and Nursing Directors to provide support, particularly on professional matters 2. The guidance emphasises the importance of involvement and ownership by clinicians. While clinical governance is about accountability, structures and processes, it will only achieve the desired outcomes of improved quality of care and public reassurance about standards of care, if it is underpinned by a wide range of activities most of which require to be owned and led by clinicians individually and collectively. Clinical governance is the means by which these activities are brought together into a structured framework. Clinical governance applies to all patient services in the NHS, wherever they are provided, and to services the NHS commissions from other organisations. Subsequent guidance, issued in , is clear that NHS Boards who contract independent sector providers, must specify in the terms of each contract that the services delivered will meet the quality standards that apply in the NHS. Suitable 2 MEL(1998) NHS MEL(2000)29 4 HDL (2005) 41 V1.1 May

3 clinical governance arrangements need to be in place so that the chair, chief executive and board members of each NHS Board have the necessary assurance that risks are being identified and appropriately managed, and that planned outcomes are being delivered. The initial guidance (updated in ) also introduced the role of the Clinical Governance Committee to oversee clinical governance and provide assurance to the board that the appropriate structures are in place. The guidance to NHSScotland to date has focused on clinical governance. In 2011, the Chief Nursing Officer s directorate focused on the issue of care governance, developing a Care Governance Manual setting out the Nursing, Midwifery and Allied Health Professional (NMAHP) contribution to the Quality Strategy. This states that care governance will bring the same level of assurance to the everyday care and experience of patients as demonstrated through the actions, interventions and caring behaviours of staff 6. The Scottish Government is looking at clinical and care governance in the context of health and social care integration, which will need to apply across all health and social care services delegated to the integration partnerships Duties of NHS Boards around clinical governance It is important to understand how clinical governance fits into the functions and responsibilities of NHS Boards. The duties of NHS Boards are set out by the National Health Service (Scotland) Act 1978 and are summarised in Rebuilding our National Health Service (2001) 7 as: - efficient, effective and accountable governance (within a framework of prudent and effective controls which enable risk to be assessed and managed) - strategic leadership and direction for the system as a whole - strategy development, including the Local Health Plan - resource allocation to address local priorities - implementation of the Local Health Plan - performance management of the entire local NHS system There is a specific legal duty of NHS Boards around clinical governance in section 12H of the National Health Service (Scotland) Act 1978, introduced by The Health Act 1999: (1) It shall be the duty of each Health Board, Special Health Board and NHS trust and of the Agency to put and keep in place arrangements for the purpose of 5 HDL(2001) Directorate for the Chief Nursing Officer, Patients, Public and Health Profession (2011) The NMAHP Contribution to the Quality Strategy The Care Governance Manual 7 Scottish Executive Health Department (2001) Rebuilding our National Health Service V1.1 May

4 monitoring and improving the quality of health care which it provides to individuals. (2) The reference in subsection (1) to health care which a body there mentioned provides to individuals includes health care which the body provides jointly with another person to individuals. (3) In this section health care means services for or in connection with the prevention, diagnosis or treatment of illness Structure of NHS Boards NHS Boards are boards of governance, not representative bodies or management boards. All members of NHS Boards - executive and non-executive - have equal status and share a collective responsibility for discharging the functions of the board and for the performance of the local system as a whole 8. All members of the NHS Board will be expected to bring an impartial judgement to bear on issues of strategy, performance management, key appointments and accountability, upwards to Scottish Ministers and outwards to the local community. 7 When NHS Boards became unified in 2001, NHS Trusts were dissolved and functions and staff transferred to new operational divisions of the NHS Board. The strategic planning, governance and performance management role of NHS Boards continued unchanged 8. Operating divisions should have specific, delegated authority to act within a defined remit without constant reference to the NHS Board and this must be backed up by clear, formal schemes of accountability 14. These divisional management teams have duties to deliver services to a defined standard devolved to them on behalf of NHS Boards, under a robust scheme of delegation. Schemes of delegation should clearly differentiate the separate functions of operating divisions and the system-wide responsibilities of NHS Boards and put in place mechanisms to devolve duties and responsibility for service delivery as close to the patient as possible. The arrangements should ensure that NHS Boards preserve their status as strategic boards of governance and not be involved in dayto-day management issues. The Chief Executive of the NHS Board has overall accountability for the performance management of the whole NHS system, and there is a direct line of accountability from Divisional Chief Executives (as described in NHS HDL(2003)11 8 to the NHS Board Chief Executive. NHS Boards are directly accountable to the Cabinet Secretary for Health and Wellbeing. The Cabinet Secretary reviews each NHS Board and their performance against HEAT targets annually. 8 NHS HDL(2003)11 V1.1 May

5 The introduction of Executive Nurse Director on NHS Boards Executive Nurse Directors were appointed as full members of NHS Boards following guidance issued in The role of Medical Directors on NHS Boards were introduced in 2003 to sit alongside the Nurse Director 8. This was done to strengthen clinical expertise, ensure that service delivery in local communities has a strong voice at NHS Board level and assist in the drive to devolve decision-making and promote clinical involvement in service redesign 8. The initial guidance 9 states the role of the Executive Nurse Director on NHS Boards includes: to share collective responsibility for governance across the local NHS system to ensure that nurse leadership is seen as integral to the corporate management of each NHS Board area to focus the contribution of nursing to strategic leadership and decision making to enhance the nursing expertise available to the NHS Board to provide an effective conduit through which other nurse leaders within the local NHS system can influence the work of the NHS Board to bring their expertise to the Board in a number of areas such as clinical quality, patient responsive services and health promotion The subsequent 2003 guidance made it clear, following the expansion of the function of NHS Boards to participate in effective and proactive regional planning, that: Executives with key clinical leadership roles, such as Directors of Public Health, Directors of Nursing and Medical Directors, have particular roles to play in ensuring that the regional planning agenda is taken forward pro-actively and that it keeps pace with immediate and future service demands. 8 The Nurse Director s role on an NHS Board therefore spans governance, leadership, professional and clinical expertise and regional planning. 3. Roles and responsibilities for clinical governance in NHS Scotland The roles around clinical governance can be broadly split into four levels 3 : - overseeing role clinical governance committees - delivering role management structure throughout Board, including clinicians involved in management - supporting role staff employed in activities underpinning clinical governance such as those involved in clinical effectiveness, audit, complaints handling and risk management - practising role - clinical and support staff 9 HDL V1.1 May

6 3.1. The role of NHS Board Chief Executive and Executive Directors The Scottish Government has defined what is required from the various roles needed to deliver effective governance in its agreement on governance for quality healthcare 10. This states that the role of Chief Executives and Executive Directors - including Executive Nurse Directors - in governance includes: - to be held to account for the performance and quality of services and care delivered by their NHS Board - continually improve the processes that support governance for quality in NHSScotland - provide clear, robust, accurate and timely information on the quality of service performance - lead improvement and learning in areas of challenge or risk identified through local reporting and governance mechanisms - support staff who raise concerns in relation to practice which endangers patient safety, and other wrongdoing, in line with the whistle-blowing policy - co-design agreements with local communities and partners on areas of priority for health and care services and for improving the wellbeing and outcomes of people and their communities - create an environment that values staff as well as supporting and enabling innovation While the Chief Executive of the NHS Board has overall accountability for the performance management of the whole NHS System, this accountability is discharged through the management structure within the health board 3, 8. Executive Directors, including Nurse Directors, have delegated authority and responsibility for their own Directorates or Departments 11. Example: NHS Tayside Code of Corporate Governance Provisions applicable to other Executive Directors of the Board (Medical Director, Nurse Director, Director of Public Health): Executive Directors have delegated authority and responsibility with the Chief Executive, for securing the economical, efficient and effective operation and management of their own Directorates or Departments and for safeguarding the assets of the Board. A scheme of delegation, which can form part of a health board s Standing Orders, describes the broad roles in delivering the functions of the board. It helps employees and stakeholders understand where responsibilities and accountabilities lie within the health board and supports internal control throughout the organisation 12. These can 10 Scottish Government (2013) The Governance for Quality Healthcare in Scotland An Agreement 11 NHS Tayside (April 2014) NHS Tayside Code of Corporate Governance 12 NHS Lothian (April 2010) NHS Lothian Scheme of Delegation V1.1 May

7 set out that Nurse Directors (often with the Medical Director) have delegated responsibilities around clinical governance. Example: NHS Lothian Scheme of Delegation Healthcare Governance and Risk Management Responsible Officer: Medical Director and Nurse Director Role of NHS Board: - Ensure that high quality, safe, effective, and patient-centred care is delivered across NHS Lothian. - To ensure that standards of care promulgated by the Scottish Government - Health Department, and by NHS Scotland Special Health Boards and agencies are implemented and monitored. - To ensure that there are effective assurance systems in place to provide a sound framework for healthcare governance and risk management across NHS Lothian - To ensure that there are effective assurance systems in place to provide a sound framework for information governance across NHS Lothian. Role of Executive Director led corporate function: - Ensure that effective frameworks, strategies and systems exist throughout NHS Lothian to support high quality, safe, effective, and patient-centred care. - Ensure the provision of a support function for operating units. - Support the NHS Board Healthcare Governance and Risk Management Committee. - Co-ordinates systems of organisational learning for healthcare governance and risk management. - Presents regular reports to the Board Monitoring clinical and care governance arrangements Clinical and Care Governance Committee The remit of the Clinical Governance Committee is to 13 : - oversee rather than deliver clinical governance - observe and check on the clinical governance activity being delivered by trust management - assure the board that appropriate structures are in place for clinical governance, that these are operating effectively and that action is taken to address areas of concern 13 HDL(2001)74 V1.1 May

8 The original guidance stated that the status of the Clinical Governance Committee should be equal to that of the Audit Committee 2. It should report directly to the management team and be chaired by a non-executive Trustee. It should include at least one non-executive member of the Trust management team and may include people, including members of NHS Boards or Special Health Boards, who are coopted, and may consist wholly or partly of members of the Trust management team. However the Chief Executive, Medical Director and Nursing Director will not be members of the Committee but they should attend meetings as required. The Committee should also develop mechanisms for engaging effectively with representatives of patients and clinical staff. With the restructure of the NHS, the responsibilities of Trust Clinical Governance Committees transferred to Divisional Clinical Governance Committees, a subcommittee of the NHS Board 14. NHS Quality Improvement Scotland (QIS) completed a review of clinical governance and risk management arrangements across NHSScotland in 2007 and again in The 2010 report found that all NHS boards had active clinical governance committee (or an equivalent) that were quite clear about their remit to provide assurance to the Board and the public that arrangements are in place to assure care is person-centred, safe and effective. The report found that the committees are supported by working groups with an operational focus to develop and implement improvement within specific clinical services. These groups also support devolved activity at community health partnership or operating unit level. Examples of current Clinical Care Governance Committee structures show that the Chief Executive, Nurse Director and Medical Director appear to be present on the Committee. Example: NHS Tayside Improvement and Quality Committee Purpose: To provide Tayside NHS Board with the assurance that robust governance and management systems and processes are in place and effective throughout NHS Tayside. Composition: - Minimum six non-executive members including Chair of Area Partnership Forum (employee director) and Chair of Area Clinical Forum - Chief Executive - Medical Director (Lead Officer for Clinical Governance) - Nurse Director - Director of Public Health Authority: The Improvement and Quality Committee is accountable to Tayside 14 NHS HDL(2003)11 15 NHS QIS (2007) Clinical Governance and Risk Management National Overview 2007; NHS QIS (2010) Clinical Governance and Risk Management National Overview 2010 V1.1 May

9 NHS Board and as such is authorised by the Board to approve Safety, Clinical Governance and Improvement within its terms of reference, and in doing so is authorised to seek any information it requires in this area. In order to fulfil its remit, the Improvement and Quality Committee may obtain whatever professional advice it requires, and require Directors or other offices of NHS Tayside bodies to attend meetings. The Improvement and Quality Committee reports to Tayside NHS Board. The Committee will produce an annual report for presentation to the Audit Committee Statement of Internal Control The Chief Executive, as Accountable Officer, is responsible for reviewing the effectiveness of the system of internal control within their organisation 16. They must produce a Statement on Internal Control that assesses the effectiveness of the internal control and risk management arrangements, covering overall good governance and the four specific strands of governance including clinical governance. The review by the Chief Executive should be evidenced by a report from the Clinical Governance Committee confirming that it has fulfilled its remit and that there are adequate and effective clinical governance arrangements in place. It should also include formal assurance, from Executive Directors and managers within the organisation who have responsibility for the development and maintenance of the internal control framework and risk management arrangements, that adequate and effective controls have been in place within their area of responsibility and that there have been no breaches of standing orders or failures of internal control 17. On behalf of the Board, the Audit Committee has a specific responsibility for reviewing the Statement of Internal Control. Annex 3 illustrates the relationship between the Board, its committees and its internal audit processes External scrutiny of clinical governance arrangements NHS Quality Improvement Scotland (QIS) introduced Standards for Clinical Governance and Risk Management in as part of their role to support NHS boards and their staff to develop and maintain strong and effective clinical governance and risk management arrangements. 16 NHS HDL (2002)11 17 Healthcare Improvement Scotland (2001) Person centred, safe, effective care, Developing Vital Systems: Governance and Assurance Framework for NHSScotland. Outcome of a seminar to describe a future approach to governance in Scotland February NHS QIS (2005) Standards for Clinical Governance and Risk Management V1.1 May

10 As part of the essential criteria within these standards, health boards must ensure that: 31.1 Clinical governance and/or quality assurance arrangements are in place which comply with NHS Boards statutory obligations, including a formal scheme of delegation There are effective organisational systems and processes for monitoring and reporting on the effectiveness of quality assurance and improvement processes at individual, team, operational unit/service (ie community health partnership, divisions) and corporate levels. 3a.4 Systems are in place to provide assurance of the quality of services provided by the NHS Board and those provided jointly with other agencies. The responsibility for setting and monitoring compliance against quality standards for clinical governance and risk management moved to Healthcare Improvement Scotland (HIS) when it was established. HIS developed and consulted on new clinical governance and risk management standards in , following the publication of The Healthcare Quality Strategy for NHSScotland. However the Draft Healthcare Quality Standard does not appear to have been finalised or implemented. HIS still references the original National Standards for Clinical Governance and Risk Management (2005) when carrying out Older People in Acute Hospital inspections. 4. Issues for nursing around clinical and care governance 4.1. Professional accountability All registered nurses are professionally accountable to the Nursing and Midwifery Council (NMC). The NMC code makes it clear to registered nurses that as a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions 20. The code also states that registered nurses must work with other to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community. Each member of a nursing team must be able to demonstrate accountability. This may be achieved in a variety of ways, for example staff showing evidence of 19 Healthcare Improvement Scotland Draft Healthcare Quality Standard July NMC Code V1.1 May

11 competence, job descriptions stating the range of duties related to the role and through ongoing professional development 21. Accountability holds from frontline practitioners to professional leads with strategic and governance responsibilities. Structures need to support professionals to discharge their responsibilities meaningfully. Boards have Lead Nurses embedded throughout the organisation who are professionally accountable to the Nurse Director and maintain professional leadership to nurses 22. Annex 4 gives an overview of the nursing lines of accountability and leadership NMC position on senior nurses and accountability At the NMC hearing of the Nurse Director at Mid Staffordshire Foundation Trust, the fitness to practice panel concluded that it was the Nurse Director s responsibility to ensure adequate nursing provision and safe staffing levels. Not doing this amounted to misconduct and her fitness to practice was impaired. Jackie Smith, NMC Chief Executive and Registrar has said publicly that The case raised important issues about the responsibility of nurses who hold senior management positions and their duty to ensure the protection of the public 23. She has also said that it is a distinct possibility that other nurse directors could face fitness to practise panels if they failed to ensure there was adequate nursing staff to protect patients 24. The panel concluded that nursing directors could not separate their strategic roles from an operational role and that the public had the right to expect a director of nursing to prioritise the provision of quality frontline nursing services. This case illustrates that the NMC is clear that the Nurse Director is accountable for the standard of nursing care within their board area and failure to deliver this could result in their fitness to practice being impaired Duty of care and liability As well as being professionally accountable to the NMC, individual nurses also have a contractual accountability to their employer and are accountable in law for their actions Scrivener R et al (2011) Accountability and responsibility: Principle of Nursing Practice B. Nursing Standard 25, 29, Date of acceptance: January Orkney Health and Care (2012) Nursing, midwifery, allied health profession, GP and dental profession leadership framework 23 Nursing Standard. 28, 22, NMC warns nursing directors to ensure safe staffing levels Nursing Times 11 November NMC (2013) Regulation in Practice V1.1 May

12 The law imposes a duty of care on practitioners, including registered nurses and healthcare support workers, in circumstances where it is reasonably foreseeable that they might cause harm to patients through their actions or their failure to act 26. A duty of care can be owed to the same patient by several individuals and by the healthcare organisation itself. Where a task is delegated to the care professional by a more experienced practitioner, on whom the overall responsibility for providing care to the patient initially fell, the experienced practitioner may also owe a direct duty of care to the patient to ensure appropriate delegation. The NMC code is clear about the circumstances in which a task can be appropriately delegated 20. If a nurse accepts responsibility for practice which is deemed to be beyond their capability and which has resulted in errors in practice, both the employee and employer are accountable: the employee for failing to acknowledge their limitations, and the employer for failing to ensure that the employee has the appropriate skills and knowledge 27. The organisation employing the care professional may also owe a direct duty of care to the patient and be liable for systemic errors such as a fault in the system it has for training and supervising staff, or having too few staff 26. Employing organisations are vicariously liable for the actions of their employees, known as secondary liability. Where an employee was acting in connection with their employment when they caused harm to a patient, the employer is vicariously liable for their actions 26. This is especially important in the context of staff changing roles. The onus is on the employers to ensure that staff are trained and supervised properly until they can demonstrate their competence in new roles and work to appropriate standards of care Professional nurse leadership Effective nursing leadership across all settings where care is delivered ensures professional standards of care and guides decision-making on commissioning and delivery of services 28. The Joint Declaration on NMAHP Leadership 29 emphasises the key role nursing leadership has in delivering the Quality Strategy and in consolidating professional accountability from frontline practitioners, through directors of nursing to the Chief Nursing Officer. NMAHP leadership aims to: create a culture of quality, innovation and excellence within a strong system of professional values, responsibility and accountability 26 Cox, C( (2010) Legal responsibility and accountability. Nursing Management. 17, 3, NMC (2011) Advice and information for employees of nurses and midwives 28 Scottish Executive Nurse Directors (2013) Rising to the challenge of the 20/20 vision 29 NHS Scotland (2010) A Joint Declaration on NMAHP Leadership from Scotland s Chief Nursing Office, Chief Health Professions Officer and Nursing Midwifery and Allied Health Professions Leaders V1.1 May

13 take collective ownership and responsibility for joint actions that place public health, health outcomes, high-quality care and a high-quality NMAHP workforce at the heart of policy influence and engage with strategic and operational decision-making locally and nationally In relation to clinical and care governance in particular, NMAHP leadership should lead, influence and secure the safety of individuals, families, communities and staff through robust and coherent professional infrastructures and processes and the use of evidence, leading to improved outcomes 29. NMAHP leaders also have a key role to Quality-assure and assess the impact of local and national plans in accordance with professional standards, productive principles and quality dimensions, including scrutiny of individuals, families and communities experience of care, compassion, dignity and positive relationships The role of Nurse Directors Example: Job description for Director of Nursing Forth Valley Includes: The Director of Nursing is responsible for providing advice to the Trust Board on strategic and professional issues relevant to its services, and for providing professional leadership to the Trust s nursing staff. The postholder is also responsible for achieving (on a multi-disciplinary basis) improvements in the quality of the Trust s clinical services, and for leading the public involvement agenda Clinical Governance Develops (in conjunction with the Medical Director) an organisational culture, implementation and monitoring arrangements for Clinical Risk Management and Clinical Governance so that the Trust Management Team. Public may be assured of the quality and safety of clinical services provided by the Trust Professional Standards Monitors the standards of professional practice within the Trust so that up-todate, safe practice may be assured; takes appropriate action as required. Advises on professional dimensions/requirements in recruitment and post/role development.... Clinical Governance shaping and guiding management decisions throughout the Trust in line with Clinical Governance and Risk Management practice to ensure patient safety and effective clinical practice; influencing professional practice as a result of patient feedback and methodologies. V1.1 May

14 Example: Highland s Partnership Agreement 30 role of Executive Nurse Director Includes: provide the Boards and the Highland Council with appropriate expert Nursing, Midwifery and Allied Health Professional (AHP) advice and guidance to inform decision making; be accountable for the standards and quality of Nursing, Midwifery and AHP Services; provide strategic leadership for the overall development of Nursing, Midwifery and AHP Practice and associated Workforce Planning; provide professional leadership for nursing, Midwifery, and AHP staff and services in NHSH and Highland Council, on behalf of the Board, by contributing to the Health Improvement agenda and developing exemplar clinical practice and patient centred care; work closely with the Board Medical Director, Director of Public Health and Chief Social Work Officer, to ensure that there are effective Healthcare Governance systems in place, to ensure the provision of high quality healthcare; be corporately accountable, as an executive member of the Board, for the strategic planning, resource allocation, performance management and governance of NHS Highland... ensure NMAHP professional advice is incorporated into relevant contracts with third parties. Based on the information presented, Executive Nurse Directors, supported by nurse leaders, have the following key roles in ensuring effective clinical and care governance: Professional accountability for the quality of nursing services Shared responsibility for healthcare governance, through the Nurse Director s role as a member of the NHS Board, with often a specific delegated responsibility around clinical governance Providing professional advice Providing professional and strategic leadership 5. Proposed arrangements under health and social care integration 5.1. What needs to be included about clinical care governance in an integration scheme The draft Regulations 31 of the Public Bodies (Joint Working) (Scotland) Act 2014 propose that the following must be included in an integration scheme: 30 Highland Partnership Agreement: Schedule Part 26C Role of Executive Nurse Director and Nursing, Midwifery and Allied Health Professions (Clause 8) V1.1 May

15 - The arrangements for clinical governance and care governance which will apply to services provided in pursuance of integrated functions - Details of how these arrangements will provide oversight of, and advice to, the integration authority in relation to clinical and care governance. - Details of how these arrangements will provide oversight of, and advice to, the strategic planning group in relation to clinical and care governance. - Details of how these arrangements will provide oversight of and advice in relation to the clinical and care governance of the delivery of health and social care services in the localities identified in the strategic plan. - Information on how the clinical and care governance arrangements which apply in relation to the functions of the local authority and Health Board will interact with the clinical and care governance arrangements to be established in respect of integration functions. - Information about the role of senior professional staff of the Health Board and the local authority in the clinical and care governance arrangements for integrated functions. - Information about how the clinical and care governance arrangements set out in the scheme relate to the arrangements for the involvement of professional advisors in the integration joint board Proposed membership of integration joint boards (body corporate model) The Scottish Government s policy statement for the Public Bodies (Joint Working) (Scotland) Act set out two categories of membership for the integration joint board 32 : - Voting members: these are members from the Health Board and Local Authority. Health Boards can only nominate non-executive directors and at least two need to be on each integration joint board. Where the Health Board is unable to fill all their places with non-executive directors they can nominate other appropriate people, such as clinical directors, to fill the spaces, with the approval of Scottish Ministers - Non-voting members: Non-voting members will provide professional advice in order for the integration joint board to make effective decisions about services that reflect sound clinical and financial practice The draft regulations 31 state that the integration joint board needs to include at least one person who is a chief social work officer, one person who is an 31 The Draft Regulations Relating to the Public Bodies (Joint Working) (Scotland) Act 2014 Set Scottish Government Policy Statement Integration Joint Board Section 12 V1.1 May

16 associate medical director or clinical director of the Health Board, the Health Board director of finance or one person who is a local authority proper officer, and representatives of staff, carers, service users and the third sector. Therefore the medical/clinical director is the only clinical representative that must be included on the integration joint board. Nurse Directors do not have to be included. Locally, the integration joint board may wish to add additional non-voting members, which could include the Nurse Director or senior nurse, in an advisory capacity 32, but this is not stipulated. The wording which relates to membership is slightly different in another part of the draft regulations, referring to a registered health professional employed by, and chosen by, the Health Board Chief Officer for the integration joint board The Integration of Health and Social Care: HR Short Life Working Group developed a template job description for the Joint Accountable Officer (now referred to as the Chief Officer) for an integration joint board 33. The template is not prescriptive; Partnerships are free to use the template to fully reflect the scope of the role and parameters described in the Partnership Agreement at local level. If the Chief Officer comes from the Health Board, there will also be an honorary contract between the individual and the local authority, and vice versa. The template job description includes the following responsibilities: Develop the integrated planning of Health and Social Care Services Lead the integration of services between those managed by the NHS Board and Local Authority to ensure integrated service planning and performance management arrangements are in place at an early stage Ensure that Heads of Service have the necessary systems and working arrangements in place to deliver all service requirements, including statutory and legislative requirements and advice to the HSCP Board, the NHS Board and relevant Council Committees. Design and implement, in partnership with both organisations and with their staff side representatives, organisational arrangements which are fit for purpose, take into account professional responsibilities and accountabilities and deliver Council and Board objectives on time and within budget. Develop and set standards for the joint delivery of adult health and social care services ensuring a robust performance management framework is in place to measure service delivery, and ensure continuous improvement. Ensure that all statutory clinical and non-clinical governance and professional standards are adhered to and arrangements are established to ensure systems are in place meeting professional and clinical standards. 33 Template job description for JAO, output from Integration of Health and Social Care: HR Short Life Working Group V1.1 May

17 5.3. Proposed membership of integration monitoring committee (lead agency model) The Scottish Government proposes having a single category of membership for the integration monitoring committee, with all members having the same rights and responsibilities 34. As with the integration joint board, the draft regulations only state that the integration joint monitoring committee must include 31 : at least one person who is a chief social work officer, one person who is an associate medical director or clinical director of the Health Board, the Health Board director of finance or one person who is a local authority proper officer, and representatives of staff, carers, service users and the third sector. Again, locally, the integration joint monitoring committee may wish to add additional members in an advisory committee 34, which could include the Nurse Director of senior nurse. 6. Analysis of the nursing issues around clinical and care governance The table below analyses nursing s role in effective clinical and care governance against the context of health and social care integration. It looks at how each of the following aspects is currently delivered, whether it can be delivered under the proposals for integration and what the potential consequences are if senior nurses are not present on the integration board: Professional accountability for the quality of nursing services Shared responsibility for healthcare governance, with often a specific delegated responsibility around clinical governance Providing professional advice Providing professional and strategic leadership 34 Scottish Government Policy Statement integration joint monitoring committee Section 16(1)(a-d) V1.1 May

18 6.1. Analysis of the nursing issues around clinical and care governance Nursing s role in effective clinical and care governance a) Accountability for the professional standards of nursing practice Basis for this NMC How is this delivered now? Line of accountability running from individual nurses at point of care, to unit/team leaders/scns, to Lead Nurses to the Nurse Director on the Health Board (see diagram in Annex 4). This is supported by clear leadership and management structures running throughout the organisation. Can this be delivered under the current proposals for integration? The current proposals do not make it explicit who is accountable for (a) the planning of services delegated to the integration board and (b) the delivery of these services. Nor does it make it clear how professional accountabilities, including for the quality of nursing care, will be discharged. Without representation on the integration board by a Nurse Director (or senior nurse who is accountable for professional standards to the Nurse Director), there is no clear line of accountability from frontline nursing staff working in services delegated to the integration board to the Nurse Director. The template job description for the Chief Officer, states that they will take into account professional responsibilities and accountabilities and ensure that clinical governance What are the potential consequences? The NMC will still hold the Nurse Director to account for the quality of nursing services delegated to the integration board. However there will not be a clear line of accountability that will allow Nurse Directors to be assured of the quality of care within these services. There is a risk to senior nurses and a risk that the nursing services delivered under integration cannot be assured to professional standards that allow the delivery of safe, effective and personcentred care to patients. With staff potentially changing roles and changing team structures within integrated working, there is an even greater need for there to be clear lines of accountability and a strong leadership framework. Employers also have secondary liability for the actions of their staff and are responsible for ensuring that staff are trained, supervised appropriately and can demonstrate competency in working to appropriate standards of care. This can only be done V1.1 May

19 Nursing s role in effective clinical and care governance Basis for this How is this delivered now? Can this be delivered under the current proposals for integration? standards and professional standards are adhered to. How can this be done if there is no stipulation that there is someone who is accountable for professional nursing standards on the integration board? What are the potential consequences? effectively through clear structures and lines of accountability to support staff. There will also be further issues when revalidation is introduced. b) Executive Nurse Director has shared responsibility for healthcare governance as member of the Health Board HDL 2002, Healthc are Govern ance Agreem ent All board members have a collective responsibility for healthcare governance. The Chief Executive retains overall accountability of performance of the NHS system. A formal scheme of delegation allows the Chief Executive to discharge this responsibility through the Executive Directors and management structure. This may The draft regulations state that the integration scheme must include information on: - the arrangements for clinical and care governance for the delegated duties, - how this relates to the clinical care governance arrangements of the health board and - the role of senior professional staff of the Health Board in clinical care governance However it is not clear whether the members of the integration board will have collective responsibility for healthcare governance in the same way that members of the Health Board currently do. Will the integration board be held to account for the performance and quality of If the Nurse Director retains the collective responsibility for healthcare governance of the functions delegated to the integration board, then they will need the appropriate leadership and professional accountability structures in place to do this. Without this, there cannot be an effective clinical governance framework and the quality of patient care cannot be assured. If collective responsibility for clinical governance and quality of the delegated services sits solely with the members of the integration board, then there must be a senior nurse on the board to ensure that this is done effectively. Previous guidance on clinical governance stressed the importance of ownership and involvement by clinicians, and the introduction of Executive Nurse Directors V1.1 May

20 Nursing s role in effective clinical and care governance Basis for this How is this delivered now? state that the Nurse Director, alongside the Medical Director, is the responsible officer for clinical governance Can this be delivered under the current proposals for integration? care delivered under the delegated duties, or will this sit with whoever they direct to deliver a particular service, eg the Health Board. In other words are the integration partnerships boards of governance, like the Health Board, or are they solely commissioning bodies with accountability for performance still being retained the Health Board and Local Authority? In addition, who is accountable for the performance and quality of services that are commissioned from the third and independent sector? What are the potential consequences? as members of Health Boards recognises the key role they play in shared governance. The draft regulations only talk about oversight of and advice on clinical governance arrangements. The Chief Officer s template job description states that they must ensure that all clinical governance and professional standards are adhered to, but not that they are to be held to account for the performance of services, in the same way as the Chief Executive and Executive Directors of the V1.1 May

21 Nursing s role in effective clinical and care governance Basis for this How is this delivered now? Can this be delivered under the current proposals for integration? Health Board are. It is therefore not clear what the role of the Nurse Director as a member of the Health Board with a collective responsibility for governance (and often a specific delegated responsibility for clinical governance) will be in clinical care governance of delegated functions. What are the potential consequences? c) Providing professional and strategic leadership HDL 2002 Executive Nurse Director provides professional and strategic leadership around clinical care governance through their role on the Health Board. This is supported by senior nurses and a leadership structure, with clear lines of accountability from front line staff to the Board Director. As with the lines of accountability, there will be a gap in the leadership structure of nursing for the services delegated to the integration board if there is not a senior nurse on the partnership board. A senior nurse may be asked to join locally, but this focuses on advice as opposed to accountability and leadership. Effective nurse leadership structures must be in place across all settings and throughout an organisation. This is vital to ensure a focus on professional standards, and to guide effective decision-making around the commissioning and operational delivery of services. Without a senior nurse on the integration partnership, there is a risk that decisions around the commissioning and delivery of the delegated duties do not reflect the experience of frontline nursing staff or the needs of patients, and that the professional standards of nursing cannot be assured. V1.1 May

22 Nursing s role in effective clinical and care governance d) Providing professional advice Basis for this HDL 2002 How is this delivered now? Executive Nurse Director provides professional expertise, focused on quality of clinical care, to the NHS Board Can this be delivered under the current proposals for integration? The medical director or clinical director (who is likely to be a medic) will be present on the integration board to provide professional advice. However medics would be unable to provide professional advice about nursing, in the same way Nurse Directors would be unable to provide professional advice about medics. Senior nurses may be asked to join locally, but the regulations as they stand would not require boards to do this. What are the potential consequences? Previous guidance on clinical governance recognised the importance of Nurse Directors and other senior nurses providing professional advice. This is vital for the effective commissioning, planning and delivery of quality services. Only having a medical director in an advisory role on the integration partnerships will lose this valuable nursing expertise. This is even more important when considering that 15 out of the 18 proposed delegated health services are delivered by nursing staff. The distinction between clinical advice and professional advice is also not clear. The Policy Statement 32 and recent Clinical and Care Governance Group meeting paper talks about requiring professional advice to ensure that decisions reflect sound clinical or social care practice. Is this around seeking advice about how particular professions can work to deliver the best care? Or is it about seeking advice on the best clinical care decisions? V1.1 May

23 Annex 1: Definitions Terms and definitions around governance, accountability and responsibilities do not seem to be used consistently. There needs to be clarification and agreement of terms. Examples of some definitions are below: Clinical and care governance: A robust system for assuring high standards in the delivery of safe, personalised and effective health and social care services. Embedded from frontline staff to corporate boards, good care governance will define, drive and provide oversight of the culture, conditions, processes, accountabilities and authority to act of organisations and individuals delivering care 35. Professional responsibility: a set of tasks or functions that an employer, professional body, court of law or some other recognised body can legitimately demand 36 Professional accountability: demonstrating an ethos of being answerable for all actions and omissions, whether to service users, peers, employers, standardsetting/regulatory bodies or oneself 36 Professional and clinical advice: Distinction between professional and clinical advice is not always made clear. Executive Directors on health boards have a role to bring their expertise to the Board in a number of areas such as clinical, quality, patient responsive services and health promotion. 10 Integration joint boards will require professional advice, for example to ensure that decisions reflect sound clinical and financial practice 34. Professional leadership: Professional leadership structures are required to ensure that the Executive Nurse Director can discharge their duties for the provision of safe, effective and person-centred care across agencies 30. Professional leadership framework and structures need to be embedded at all appropriate levels, with clarity of professional accountability for each practitioner. 35 RCN definition provided to Scottish Government s Clinical and Care Governance group 36 Scottish Government (2012) Professionalism in nursing, midwifery and the allied health professions in Scotland: a report to the Coordinating Council for the NMAHP Contribution to the Healthcare Quality Strategy for NHSSCotland, CNOPPP, Scottish Government V1.1 May

24 Annex 2: Timeline of clinical and care governance V1.1 May

25 Annex 3: Relationships between the Board, its committees and internal audit which support the process of internal control Diagram from: NHS HDL(2002)11 Corporate Governance: Statement on Internal Control (SIC) V1.1 May

26 Annex 4: Lines of accountability and nurse leadership Helen Richens Policy Officer V1.1 May

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