1. Professor R Endacott Professor R Sheaff Professor R Jones Dr V Woodward

2. Background From 1990’s, UK gov advocate the ‘public firm’ model for public service providers NHS services are managed through a distinctive Board membership & structure Pre 2003, 2 types of Trust – acute and primary care Post 2003: introduction of Foundation Trusts operate under licence (independant regulator Monitor) more accountable to local populations less central control

3. NHS Trust Board NHS Bodies Clinical services clinical issues to influence management decisions Performance management Contestability accountability conduit leadership

4. Previous studies Greater clinical focus at NHS Trust Board level will improve the range, quality or cost of clinical care (Davies et al 2000; Marshall et al 2003). Nursing leaders in NHS Trusts often lack the skills, confidence and opportunity to ensure clinical and patient care issues are adequately discussed at board level (Burdett Trust for Nursing 2006).

5. Study Aims 1. To refine methods for measuring the concept of clinical focus 2. To examine effects of Trust Board membership on clinical focus 3. To examine relationships between clinical focus and organisational culture 4. To examine relationships between clinical focus and service outcomes

6. Design To meet aims 1 & 2, two phase design Phase 1: analysis of publicly available data (board meeting minutes, biographies of Board members) Phase 2: observation at Board meetings for at least 3 sequential meetings Phase 1 was preceded by extensive work testing measurement of clinical focus

7. Contextual data Steering Group – Directors/senior clinicians Different processes for clinical issues getting to Board Trend towards greater part of meetings closed to the public Extent of clinical discussion influenced by major events eg C Diff outbreak

8. Measuring clinical focus 2 major judgments: what constitutes an ‘item’ how to distinguish clinical from non-clinical in a replicable manner

9. An item.. a discrete issue or topic raised by a Board member. It is defined by content: - a relatively clearly bounded content, - distinct from preceding and subsequent contents of discussion.

10. Defining ‘clinical’ items...concerning the direct provision to patients of physical or psychological care or diagnoses (not the organisation thereof). Coding manual developed ClinicalNon clinical Service design and standardsGeneral board processes Clinical ethics and governanceNHS Agenda Clinical outcomesFinance Referral rates and volumeOrganisational ActivityStaffing Evidence based modelsPatient Feedback

11. Validity & Reliability Piloted through observation of Board meeting and review of minutes (n=5 Trusts) - 2 clinical academics, 2 academics Inter-rater reliability: signs of ‘rater fatigue’: unusually small number of codes per page over-arching trends that occur constantly recurring categories in large section of text Median agreement across 25 sets of minutes = 95.35%

12. Population and Sample In Feb 2008, 298 Trusts listed on Department of Health or Monitor websites: 150 Primary Care Trusts (PCTs) 92 acute non-Foundation Trusts (non-FT acute) 56 acute Foundation Trusts (FT) Goal: 35 sets of mins/type of Trust = 105 Sample: 2 difficulties Availability of minutes Accessibility of minutes

13. Sample - availability 1. One additional FT had minutes available but >9 months old Significant - Chi-Square 1.548, p=<0.0001 TypeWebsites randomly selected Recent 1 minutes downloaded % recent minutes not available FT563536.4 Acute non- FT 38357.9 PCT38357.9

14. Sample - accessibility PCT and acute non-FTs: 8.6% (6/70) required ‘search’ facility 91.4% (64/70) accessed via max 4 menus Majority located in ‘About us’ section Acute FTs All 56 sampled to reach sample size (35) 51% (18/35) accessed via max 4 menus Some stated minutes could be obtained via ‘FoI’ Act, for which a charge may be levied.

15. Early results Mean no of items (range) Mean % clinical items (range) Foundation Trust36.8 (18-64)12.91 (5.5 – 24) Acute Trust58.8 (30-100)15.54 (3.6 - 38.7) PCT64.9 (52-90)20.4 (6.0 – 47.8)

16. Early results - the first 30 Trusts

17. Ethical challenges Access to private part of Board meetings – requires all Board members to consent Lengthy process – personal introductions One outright refusal from Board Chair – no reason given

18. Conclusions Significant difference in availability and accessibility of Board minutes between Foundation/non-Foundation Trusts Trends in data to date: Fewer items identified in FT minutes Lower % of clinical items in FT minutes Steering group input essential to understand context

19. Next stages … Survey of Board members Team Climate Inventory Analysis of publicly available service outcome data Examination of relationships between Board membership, Clinical focus, Organisational culture and Service outcomes