Opening up to close scrutiny
In a continuing series on foundation trusts, Richard Gregory explains why the governance model will play a central role in securing quality patient care.
Focusing on governance could not be more timely, with more pressure than ever before on providers to maintain or improve quality while at the same time meeting year-on-year efficiency demands. With the impending publication of the Francis Inquiry, all foundation trust directors and governors should be asking themselves whether their governance model is robust enough to prevent another such event.
Accountability to the communities we serve - through an elected and stakeholder representative council - is the distinctive feature of FT governance. But it is easier said than done - to make it truly effective requires the right culture, communication channels and framework in place.
FT chairs who preside over both board and council have a tremendous responsibility to ensure this happens, supported by their senior independent directors and lead governors.
The prize is a hospital that is open to daily scrutiny and learns through that process - a real defence when managements and boards have to make difficult calls close to the wire between quality and affordability.
Our governors and members are our eyes and ears on the ground - they know best the quality of care being provided.
But to capture this input the trust needs to have the appropriate response mechanisms. Some issues need management action on the day, others need proper board reflection and discussion.
Achieving the right relationship between nonexecutive directors and governors is part of the challenge. At Chesterfield Royal Foundation Trust we have found that encouraging our NEDs and governors to meet several times a year outside board and council meetings, with an open agenda
- to talk and listen to each other
- has helped build the important foundations of this rather unique governance relationship. Governors should be patient champions, with unfettered access to all areas of the hospital.
- Members should not just receive newsletters but be consulted on strategic priorities. Our last members’ survey produced more than 2,000 responses, which helped shape our strategic review.
Keep it simple
I also believe we need to make it easier for governors to hold our board to account. It is, of course, a 24/7 responsibility - but its effectiveness is set by the number of council meetings held, the time and support to assess a mass of performance statistics, the level of governor training and personal commitment, the level of scrutiny access permitted, and the responsiveness of board and management (through its practical processes as well as intent).
At Chesterfield our governors meet every six weeks, with a very active patient and public involvement committee and regular ward visits. As well as the regular quality reports, performance returns and strategy reviews, we are also introducing a standing agenda item called simply “holding the board to account”.
In their forward work, programme governors will be able to select any service or strategic issue and ask executive directors and NEDs to report. Hopefully this will help keep it simple and add value in a more focused way.
And we are quick to react when changes need to be made.
For example, we have just opened our new ophthalmic centre following significant investment to improve the service. The decision was taken following initial feedback from a council of governors meeting that exposed the emerging problems of the old service in public, with GP leaders present.
Governor/member feedback does not replace management systems, it assures them. It also stimulates an internal critical challenge and helps inform the board. I welcome the governance structure of FTs. What organisation would not want to be so closely tuned into the interests of its customers?
Yet sometimes I think the FT model lacks the recognition it deserves. Accountability should be based on the total service to the health community, with commissioners as well as providers held to account and valuing the type of community accountability structure which FTs have pioneered.
It is not the only defence of patient interests, of course. But, ultimately, it is about the community the hospital serves being satisfied on a daily basis, and being enabled to identify and voice concerns if standards drop.
Richard Gregory is chair at Chesterfield Royal Foundation Trust.