Published: 24/02/2005, Volume II5, No. 5944 Page 23
Ellie Scrivens says devolved management can only work if boards embrace their new reponsibilities
Reducing bureaucracy in the NHS by taking away administrative burdens imposed by the Department of Health is a sound idea, but brings with it much greater responsibility for NHS boards.
The only reason for having a board is to ensure that the organisation's objectives are achieved appropriately, and in the NHS, to ensure decisions are taken in a way that meets public demands for accountability.
Under devolved management, NHS organisations must have a clear view of their objectives and show they can identify and manage risks. Failure can lead to accusations of board negligence, which means at best public criticism, at worst, possible criminal prosecution.
Board members are individually responsible for making sure that they balance a strategic vision for the future of healthcare with immediate risks such as health and safety, data protection and environmental management.
Previously, board members were afforded a degree of support and protection for bottom-up risks through the now scrapped controls assurance standards.
However, it can be argued that the controls assurance process, with its emphasis on an annual return, prevented boards from developing a responsible attitude to risk.
A less prescriptive framework, in tune with the messages of devolved management, is currently being devised by the Department of Health to enable boards to be fully accountable for all organisational activity.
The standards for better health are divided into domains which describe the expectations of providing safe healthcare, effective clinical care, good governance, a central focus on the patient, accessible and responsive care and an emphasis on public health.
The performance framework, together with the domain statements, provide focused and broader strategic objectives to help boards devise and evaluate better ways to deliver services.
Boards will be expected by the Healthcare Commission to monitor performance against these standards. The Health Care Standards Unit was set up in August 2004 at Keele University to assist the DoH and NHS in the use of standards, particularly the new national standards for better health. HCSU works by collaborating with NHS and DoH staff to monitor the standards and deepen understanding of how they can be used.
To help continue this, HCSU has been asked by the DoH to develop assurance markers for all the standards for better health. These are management tools to help board members ask questions about the internal controls systems and the management of risks associated with areas covered by the standards.
The standards for better health are based on existing policies and regulatory requirements and HCSU has developed descriptions of the main policies, called signposts. Discussion boards have been set up to let NHS staff raise questions and discuss issues with their colleagues.
HCSU is also setting up specialised master classes looking into, for example, using the standards to set organisational objectives, develop the assurance framework and improve commissioning.
Under true devolved management, conceptual frameworks are as prescriptive as guidance can get.
Boards will have to recognise that they, and only they, are in control of their organisations and responsible for all the actions, clinical and non-clinical, taken on their behalf.
Freedom does have a price and its currency will be the ways in which boards are held to account.
Professor Ellie Scrivens writes as head of Keele University's Health Care Standards Unit www. hcsu. org. uk