Improving the Family Health Board governance processes at NUTH

Summary

Doug Woodcock and Marieke Emonts share Newcastle upon Tyne Hospitals' Family Health Board governance improvement journey.

Content

The governance improvement journey for the Family Health Board at the Newcastle upon Tyne Hospitals NHS Foundation Trust began following a Care Quality Commission (CQC) inspection in January 2024. The inspection report highlighted some room for improvement, particularly in the Well-Led domain (a framework used by the CQC to assess healthcare organisations on leadership, governance, culture, innovation and improvement).

One of the key areas that the Trust as a whole looked to strengthen in response to this was oversight of governance processes via a more robust governance framework.

As is often the case with governance work, change has been intentionally gradual, with time taken between each step to ensure it has been implemented effectively. Support from the Trust's corporate team was essential to ensure that processes within Family Health were in line with any Trust-wide approach. For example, when the new board-level governance meetings, called the Quality Oversight Group (QOG), were implemented, Trust-wide terms of reference were introduced for these to ensure each board had guidance on what should be monitored and reported on. By having a ‘shared’ terms of reference, ensuring each board QOG captured and reported on similar themes, enabled the executive team to have a greater level of check and challenge at each Board Quality Performance Review (QPR) meeting.

From the QOG meeting, both directorates within Family Health (Women’s Services and the Great North Children’s Hospital) established directorate quality and safety (Q&S) meetings, which meet monthly and report into the QOG. The idea behind this, as with most governance structures, is that the ‘detail’ of most governance-related issues is monitored at the directorate Q&S meeting, and even at individual departmental level, and reported up for information and/or assurance or escalation, with the overall responsibility for monitoring and action remaining within the directorate in most cases.

At each level, the template for the meetings is the same but with different levels of detail.

Timing of the meetings is planned so that issues that need to be escalated from departmental to directorate, or from directorate to board level, can happen in quick succession to avoid delays. Within the directorate, speciality Q&S meetings also occur, including Morbidity and Mortality (M&M) meetings and others as needed.

It hasn’t all been smooth sailing! As part of the initial governance movement from a Trust-wide perspective, the Trust recruited for non-clinical governance and patient safety leads, with most boards having one appointed. The Family Health Board was the last to appoint, with their lead only in post in October 2025.

In May 2025, the Trust switched its incident reporting platform from Datix to InPhase for risk management, incident management and a host of other governance-related processes. As such, there was a real focus on getting incidents that had been reported on Datix investigated and closed as soon as possible after the switch to InPhase. Timely investigation of incidents remains an area within Family Health for potential improvement, but ongoing recruitment/upskilling of existing staff (such as new Q&S leads for sub-directorates within the Great North Children's Hospital) have been carried out to help with this.

We would never claim we have absolutely everything sussed, but a recent external audit into the Family Health Board governance processes returned a report that was mostly positive, declaring that there was a clear escalation process for areas of concern within the board. There were a few minor recommended actions included in the report, but these were all actioned within three months of receiving the report.

Governance work and the goal of improvement never stops—the priorities change as old goals are met, but there are always ways to be better!

About the author

Doug Woodcock is a Clinical Governance and Patient Safety Lead for the Family Health Board at Newcastle upon Tyne Hospitals (NUTH) Foundation Trust.

Marieke Emonts is a Paediatric Infectious Diseases and Clinical Director for the Children's Directorate at NUTH. Until recently she was the Quality and Safety Lead for the Family Health Board. Marieke is currently chair of the Patient Safety Paediatric Lead Network.