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Kark review publishes recommendations to improve NHS leadership

The government has today (February 6) published the review by Tom Kark QC of the Fit and Proper Person Test (FPPT) - which came into force on November 27, 2014 - and his series of recommendations about how NHS leadership can be improved.


The review focuses on the FPPT to assess whether it works in its current form and how it might be adapted to ensure better leadership and management and to prevent the employment of directors who are incompetent, misbehave, or mismanage.


The review found that the promises made by the government in its ‘Hard Truths’ response to Sir Robert Francis QC’s report on Mid Staffs that a new FPPT would enable the CQC to bar directors who are unfit from individual posts has not actually happened. The CQC in reality has no power over individual directors and is not structured to regulate individuals. Hence, the task of acting on the FPPT has been left to Trusts themselves. Tom Kark believes that this responsibility should lie with the Trust, but finds that not all Trusts are applying FPPT properly and it is therefore failing to be a significant tool for improvement. 


The review also finds a “startling lack of information” about the people acting in Board director positions within NHS Trusts, saying there is no centrally-held list of individuals, their background, qualifications and training to equip them for the role they are undertaking. 


It highlights a significant fault across the service as the lack of required, adequate and quality training about “what the function of a Board is, how a good Board operates, what a good Board ‘looks like, how to be an effective Board member, how to ensure there is independent analysis and assessment of the Board function and to provide support and training where required.”


Raising the bar for the FPPT with even higher standards that make it easier to exclude or bar a director is not the answer. Apart from the issue already highlighted whereby many Trusts are not applying the test properly anyway, the dearth of suitably qualified candidates who are willing to take on senior roles and the high level of churn lead Kark to the conclusion that the answer lies in a system that equips senior management at Board level in the NHS with the skills they need and that assesses them and continues to assess them throughout their careers, giving them support and further training as necessary.


Where the FPPT does need strengthening is to allow it to do the task it was originally intended to do, which is to ensure that where directors commit serious acts of misconduct or mismanagement they are subsequently barred from working in the health service. The practice of quietly moving such an individual to another post within the same Trust or agreeing a pay-off with a bland reference and a confidentiality agreement that allows the individual to apply for a job with another Trust must be stopped. 


Among the seven recommendations set out by the review are:

* All directors should meet specified standards of competence, and training should be given where necessary

* A central database of directors should be created to hold relevant information about qualifications and history

* The creation of a mandatory reference requirement for each director

* The FPPT should be extended to all Commissioners and other Arms Length Bodies, including NHS Improvement and NHS England

* An organisation should be set up that will have the power to disbar directors for serious misconduct, with a strong definition of what constitutes serious misconduct


Speaking to healthcare professionals at the Royal Society of Medicine on the importance of the tight leadership for patient safety, Secretary of State for Health and Social Care, Matt Hancock, welcomed the findings of the Kark review, saying a better structure is needed “to support and hold to account.” 


He explained: “Kark recommends that all directors must meet minimum competency standards to sit on the board of any health organisation, and where training is needed to meet those new standards then it should be made available.


“He also recommends a central director’s database where information about qualifications and employment history can be easily accessed.


“These new recommendations will ensure the fit and proper persons test is met and that unqualified or unsuitable staff can’t just move somewhere else in the NHS. We accept these recommendations in full and will get on with implementing them immediately.”


He also confirmed he has asked Dido Harding, Chair of NHS Improvement, to consider Kark’s other recommendation and how they could be implemented throughout the health service. 


The Secretary of State described the right leadership as “critical.” In addition to a better structure, he also echoed Kark’s comments about cutting the churn rate of senior staff by attracting the best talent and firing fewer people and confirmed that whistleblowing will be encouraged. “Despite our best efforts, mistakes happen,” he said. “Mistakes should be seen as an opportunity to learn and improve, not a need for cover-up and denial.”


Download the full review here.