Walking a tightrope? Using case study research to understand how hospital boards are managing the tension between constrained funding and patient safety

Background and objectives
The main purpose of the study which we report here, funded by the Department of Health Policy Research Programme and with a completion date of June 2017, is to establish how different hospital boards, in varying circumstances, have sought to implement the recommendations of the Francis Inquiry Report to improve leadership, and the organisational and cultural effects of the changes. The study comprises a literature review, scoping interviews, a national survey of hospital board members, and six in-depth case studies of hospital trusts and foundation trusts.
In this paper, we focus on the case studies, exploring the tensions experienced by hospital board members individually and collectively as they seek to balance their twin responsibilities for finance and care quality, in times of significant financial pressure on the NHS.
Methods
Case study research in each site comprised: 12 semi-structured interviews with executive and non-executive board members; observation of 2 full meetings of the hospital board; a survey questionnaire of all departmental and ward managers; and focus group discussions with staff-side representatives and local patient groups/foundation trust governors. Data are being analysed within- and across cases, using a thematic framework developed from the Francis Inquiry Report, refined following initial analysis by the research team of a sub-set of interview transcripts independently coded by all four case study researchers.
Results and implications
Some boards were more successful than others in managing trade-offs such as that between quality and finance, and we are analysing the ways in which boards converged or diverged in their handling of such issues, with reference to theories of board leadership approach (e.g. agency, stakeholder, resource dependency, stewardship). Analysis and synthesis of findings will be completed by May 2017. Emerging themes likely to be reported include:
• Some hospital boards have made significant investment in nurse and medical staffing as a response to the Francis Inquiry, and this is considered by board members and departmental managers to be an important action to improve care safety and quality, whilst being the greatest cost incurred as a result of the inquiry report.

• This investment in additional staff is now under significant pressure as wider NHS funding is constrained and national caps on agency and bank staff have been imposed.

• Boards are very clear about their responsibility to assure safe and high quality care, and assert that it is this duty which ultimately will override that of balancing the books, albeit they recognise the performance management risks of taking this stance.

• Workforce pressures are considered the biggest challenge facing hospital boards, as revealed by our national survey, with concern expressed in the case studies about how to address this, given pressures such as safe staffing recommendations following the Francis Report, a lack of specialist staff, and difficulties retaining newly qualified nursing staff.

• The challenge of ‘walking the tightrope’ of quality and finance is putting significant pressure on NHS hospitals and their boards in particular, for the boards are the ‘shock absorbers’ between local operational pressures and demands from commissioners and national regulators.