NHS governance: all aboard

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Boards will play a significant role in taking PCTs to the next level with the help of a DH development framework

Primary care trust boards will be vital conduits to the delivery of world class commissioning. The new PCT board development framework from the Department of Health's world class commissioning team aims to assist this progress.

Sefton PCT chief executive Leigh Griffin suggests that "for PCTs to move from good to great, boards must be a force for continuous improvement and public accountability".

He explains: "Board development is critical for boards to demonstrate strategic leadership, ambition, focus, challenge and understanding. The raised expectations on PCTs must, first and foremost, be understood and driven at board level".

Marianne Griffiths, director of commissioning and delivery and deputy chief executive of NHS South East Coast, observes: "It's important that PCT boards are able to explain coherently why they've developed specific priorities for their population in terms of reducing inequalities and improving health.

"All boards want to do this, but some may need help to describe their aspirations in an effective manner. Therefore board development will also support boards to have helpful and meaningful conversations with patients and the public."

Gary Belfield, director of commissioning at the Department of Health, observes that international evidence suggests the two main features of any organisation making a real difference and starting to succeed are "having great top leadership and a strong, cohesive board".

"We've been working with the strategic health authorities since March 2007, trying to clarify what things need to be defined and produced at the national level, and they told us there was a real need for some board-level support for PCTs.When we talked to PCTs about this idea, they were very upfront about their needs, telling us that they would welcome support," he says.

Mr Belfield points out that with the renewed focus of PCTs on world class commissioning, "we need the whole board focusing on commissioning - even those with provider arms. On average, every PCT spends about half a billion pounds a year on the health and well-being of its population. Developing a world class organisation that performs well on the 11 world class commissioning competencies will help ensure this money truly delivers long term health gains for the people in this country.

"So a key question for the board is how to support their organisations in delivering the 11 competencies."

Mr Belfield also describes an important lesson learned from foundation trusts' boards: an identifiable common feature of those who made the fastest progress was having boards that:

moved quickly;
had a strong grip;
had fantastic governance;
asked the right questions.

Boards need to avoid the pitfalls of parochialism: they need to understand provider economics and really know about the services they commission.

This is a big advance on what many PCT boards have done in the past, and also brings a stronger role for non-executive directors.

Gary Belfield emphasises that developing non-executive directors is a priority.

"We recognise that many non-executive directors only spend a few days a month in the PCT, and may have been appointed mainly on the basis of representing their community, but success is dependent on developing the whole board together".

A different skill-mix is needed to deliver world class commissioning, and it is hoped that existing directors, including non-executives will develop and adapt accordingly.

To make the process of choosing board support as easy as possible, the world class commissioning team has vetted and approved seven organisations, and created a simplified contract form and application process. No more than four weeks should need to elapse between the moment a board decides it needs help and the arrival of a provider to start working with them on site, according to the PCT's convenience.

As PCTs go through the inaugural assurance process, each will be able to identify particular areas for development.

As a result, the world class commissioning team believes many PCTs will be tapping into the board development framework over the next 12-18 months.

The content of the training modules these providers offer will vary by provider - certainly not one-size-fits-all - and modules will change every year, as PCTs' competencies and information needs develop.

Current available modules include examining how a board actually functions and works together; information needs; how to get a real grip of the organisation; what reports to see and what questions to ask (that is, anonymised patient data details); ensuring your five-year financial and strategic plans are deliverable.

Gary Belfield concludes that "this is not just about one-off projects - we think PCTs may want to develop longer term development programmes over many months or perhaps even years."

THE 11 WORLD-CLASS COMMISSIONING COMPETENCIES