The silencing of nurse voices at the top tables of the NHS is “wrong and needs to be redressed”, a leading barrister has warned.
Tom Kark made the caution as part of his review into the fit and proper person test (FPPT), which is used to ensure directors of care services are equipped to carry out their roles to the highest standard.
“Nurses entering the boardroom sometimes have less confidence to speak up”
In light of Mr Kark’s findings, health secretary Matt Hancock has agreed to introduce new minimum competency standards that all applicants will have to meet to gain a seat on the board of a healthcare organisation.
The FPPT was introduced in 2014 in response to failures in leadership highlighted during inquiries into the care scandals at Winterbourne View and Mid Staffordshire NHS Foundation Trust.
Mr Kark, who was counsel to the Mid Staffs investigation, was asked by the government to review the effectiveness of the FPPT, after similar issues were uncovered at Liverpool Community Health NHS Trust.
A review conducted by Dr Bill Kirkup determined that poor leadership at the trust between 2010 and 2014 resulted in a widespread culture of bullying and harassment and declining patient care.
Source: Department of Health and Social Care
In his report published yesterday, Mr Kark said the FPPT needed to undergo catalogue of changes to become fit for purpose.
He warned that the test, which is carried out by employers and overseen by the Care Quality Commission, was regarded by many as “simply a distraction or a tick box exercise”, which has “no real effect on patient care or safety”.
Mr Kark, who was assisted in his investigation by barrister Jane Russell, concluded the FPPT was “ineffective” in ensuring that directors had the right skills for the job, because it had no criteria to measure their competencies.
He noted that “anyone with almost any background” could apply for the post of an executive or non-executive director at a trust.
Concern was also raised in the report about a lack of compulsory training for board-level managers.
“Many regard it as a poisoned chalice because of the stress which attaches to the job”
The introduction of specific leadership training was cited as a way to encourage more nurses into top roles.
“The point was repeatedly made to us that for some, including some clinically qualified doctors and nurses, the step up to the board is a significant one,” Mr Kark said in his report. “Some training would help make that less of a high step.”
In addition, Mr Kark said he was told by then chief nursing officer Jane Cummings that executive nurses were sometimes not taken seriously by their peers and that training would help to address this.
“We were told by the chief nurse (Jane Cummings) that there was evidence that although nurse empowerment was progressing at ward and theatre level, nurses entering the boardroom sometimes have less confidence to speak up and their contribution is not deemed as valuable as others,” Mr Kark said in the report.
“This is obviously wrong and needs to be redressed. We were told that the right training would do much to assist,” he stated.
Meanwhile, Mr Kark highlighted that, while executive nurses would need to prove their ongoing competence through revalidation, other non-clinical directors did not. “We think the field should be more balanced,” he said.
He noted that routine assessment of directors was not mandatory in every NHS trust, “despite the very large sums of public money expended by them and their overriding duty to the patients and public they serve”.
While stopping short of suggesting a full revalidation programme for all directors, Mr Kark said an appraisal process “ought to bring some benefit to those who embrace it”.
“I know that NHS leaders have some of the toughest jobs in the country”
Mr Kark said he hoped introducing necessary skills and competencies for directors and providing them with training to develop these skills would make the job “more attractive and better shielded from the slings and arrows of political interference”.
The report referenced research by the King’s Fund think-tank in 2014 that found 7% of all chief executive positions were unfilled and the average tenure for those taking on these jobs was just 700 days.
“The reality is that, despite the importance of the job, many regard it as a poisoned chalice both because of the stress which attaches to the job of senior executive in an NHS trust and because of the surprising lack of security of such posts,” Mr Kark said.
As well introducing competency standards, the Department of Health and Social Care has committed to Mr Kark’s suggestion to set up a central database of directors listing their qualifications, previous employment and performance.
Mr Kark also highlighted in his report that the FPPT did not not stop “the unfit or misbehaved” from moving from one senior job in the health system to another usually for very high sums of money – known as the “revolving door”.
He noted how under the current system directors who committed serious misconduct were able to obtain senior jobs with other trusts because former employers were prevented from including this information in their FPPT reference through “compromise, confidentiality and settlement agreements”.
“We owe it to them to listen to their views”
To address this issue, Mr Kark urged the government to set up a new organisation with the power to suspend and to disbar directors who had been found guilty of serious misconduct.
He also put forward the idea of making it mandatory for trusts to submit ”full, honest and accurate” employment references where a director was moving from a post.
The government will consider Mr Kark’s other recommendations as part of its “workforce implementation plan”, which is due to be published later this year and will set out how promises made in the NHS Long Term Plan around staffing will be met.
Mr Hancock said: “I know that NHS leaders have some of the toughest jobs in the country.
“We need to support them with the skills and training they need so they can lead their organisations effectively and create the right culture for staff and patients,” he said.
However, Chris Hopson, chief executive of NHS Providers, which represents trusts, raised concerns that employers had not been consulted before the government accepted the recommendations from the report.
“Trust board directors have a difficult and complicated set of responsibilities,” he said.
He added: “We owe it to them to listen to their views and carefully think through any changes to the environment in which they operate. There is a danger of failing to do that here.”