To commission effectively, consortia will need governance arrangements that create confidence and trust, and build legitimacy and partnerships, writes The Health Foundation chief executive Stephen Thornton.
With one exception, the NHS in England seems to be getting its act together on quality governance.
There is growing international recognition that healthcare governance arrangements make a positive impact on quality. Research by Jha and Epstein, for instance, shows how US hospital boards’ attitudes to quality and safety relate to patient outcomes. The Health Foundation is funding a similar study in the UK, to be presented at the NHS Confederation conference.
In England, the National Quality Board recently published a guide to quality governance for provider boards that said: “Individuals working in clinical teams providing NHS services are at the front line of ensuring quality of care to patients. However, ultimately, it must be the board and leaders of provider organisations that take final and definitive responsibility for improvements, successful delivery, and equally failures, in the quality of care.” The guide is an attempt to help them.
Meanwhile, Monitor ensures that no trust in England can achieve foundation status without addressing its quality governance and none can neglect its continuing importance without running the risk of breaching Monitor’s compliance arrangements.
Four months ago, similar work seemed to be proceeding apace regarding commissioning consortia. At a workshop for potential consortium leaders run by the National Institute for Innovation and Improvement, there was healthy debate of an early draft document entitled Governing GP Commissioning. Aware of the government’s disdain for centrally imposed structural solutions, this was not even expressed in terms of guidance, simply as being a “discussion document”.
However, it was based on a thorough review of the evidence. It drew on material from the private, statutory and third sectors, quoted authoritative sources and addressed research and guidance developed in the aftermath of the 2008-09 financial crisis. It offered straightforward, sensible and well-articulated advice. Yet this work has still to see the light of day. The overwhelming weight of evidence suggests a laissez-faire free-for-all is fatally flawed. As the recent Commons health committee report on commissioning argued, the consortia should reflect “standards of good public sector governance”.
A finite resource
But, could it not be argued that commissioning is quite different from provision? So long as providers are mindful of their governance arrangements, are not patient and community interests met?
That depends on the view you take of commissioning. For me, it is a great deal more than mere transactional contracting. Commissioners’ decisions are potentially as quality-enhancing or damaging as those taken by providers. Quality is not an endlessly available commodity. Operating within a budget where the sum total of effective interventions will always be greater than the funds available, commissioners have to make tough choices. Placing societal limits on healthcare via trade-offs, priority setting and, yes, via occasional care denial, is what commissioners exist to do. Otherwise they are simply a worthless overhead. In this context, the quality governance for consortia is vitally important.
The starting point is ensuring consortia have generic good governance across the piece, not just in quality. The evidence is clear. Having individuals, such as non-executive directors, governors or members, who are totally independent at the governance level is the only effective way of maintaining public confidence and trust. They guarantee transparent decision making, ensure conflicts of interest are not in play, have oversight of the proper checks and balances for the stewardship of public money, and bring a wider range of perspectives and skills to bear. They are the all-important grit in the oyster, to guard against groupthink.
Ministers envision power transferred to patients. Commissioning consortium governance arrangements need to be designed to assure this shift. This will require skilful strategic leadership that goes beyond financial probity. For instance, consortia will need to adopt approaches to promote systematic engagement to allow fair decisions to be reached based on the best evidence.
Consortia will need governance arrangements enabling them to build legitimacy. Without it they will fail to carry the mantle of lead local commissioner. They will encounter strident opposition from health and wellbeing boards dominated by the local authority, whose members will carry democratic legitimacy. They will find their tough decisions challenged.
The government must ensure that Governing GP Commissioning is used to inform the evolving debate about the right forms of governance for consortia. At this point, we need clear thinking based on evidence and sound principles.