Good leadership and management key to patient safety, says Commission

The Healthcare Commission has urged boards of all NHS trusts in England to heed the lessons from serious failings in healthcare services.

It highlighted the importance of good leadership, effective management and systematic use of information.

The Learning from Investigations report reviewed all investigations undertaken by the Commission under its statutory powers from August 2004 to April 2007. Investigations are undertaken where patient safety is seriously at risk.

The Commission said all organisations face change and have to deliver on objectives. The message from the findings of investigations is that trust boards need to do this and deliver on the basics of quality of care and safety.

Poor leadership was a problem in nearly all of the investigations carried out by the Commission.

Some boards had been focused on mergers or targets at the expense of their broader activities.

Lack of continuity in leadership was a problem in some trusts, where frequent changes in management were a factor in poor care. Bullying and harassment by managers was a factor in two cases investigated. The Commission found there was a fine line between promoting change vigorously and bullying.

Investigations often uncovered a breakdown in leadership and management, with a lack of clarity on responsibilities from board to ward. Poor teamwork, either between management and clinicians or between clinicians themselves was another common factor in failings.

Anna Walker, the Commission's chief executive, said: "Good leadership means not taking your eye off any aspects of the trust's activities - no ifs and no buts.

"In practice, this means ensuring staff are encouraged to speak up about concerns. Given that modern medicine involves risk, it means monitoring these risks and ensuring that issues such as infection control are high on the management agenda.

"It also means never underestimating what it takes to manage change, as well as ensuring those most in need are looked after properly. Above all, it means boards putting systems in place to turn their vision of quality care into a reality on the wards.

"There are trusts across the country that are succeeding at doing all of this while still managing change and meeting targets."