A business critical briefing from HSJ’s Fundamentals of NHS Governance conference
- Paul Stanton, professor of governance, Northumbria University, and CEO, Southminster Consultancy Associates
- Deborah Arnot, deputy director of organisational development support, NHS North West Leadership Academy
- Lynn Betts, independent consultant, Quality Governance Ltd
- Jay Bevington, director, public sector assurance advisory practice, Deloitte
- Julia Brown, chief operating officer, NHS Enfield community services
- John Bullivant, director, Good Governance Institute
- Stuart Emslie, assistant director, Centre for Corporate Governance and Ethics, Birkbeck, University of London, and visiting fellow, Loughborough University Business School
- Linda Hutchinson, director of registration, Care Quality Commission
- Calum Pallister, head of trust practice business, Audit Commission
- Brian Terry, head of integrated governance, NHS Gloucestershire
Introduction, Paul Stanton, professor of governance, Northumbria University, and CEO, Southminster Consultancy Associates
- Healthcare organisations are facing escalating demand along with constrained resources.
- Governance is the application of collective wisdom to uncertainty.
- Organisations need to be risk sensitive and politically aware, but they also need to be less risk averse and less politically obsessed.
- Boards should shift their focus from the present towards the future, spending 30 per cent of their efforts on the present and 70 per cent on the future.
- Commissioners and providers should enhance their clarity of functions, their scrutiny, transparency and probity.
- Download Mr Stanton’s presentation
The Care Quality Commission and regulation, Linda Hutchinson, director of registration, Care Quality Commission
- The CQC wants services to meet essential standards of quality and safety.
- All providers of health and social care are required to be registered with the CQC. There will be a single set of registration requirements for all settings. The CQC will judge each provider and either register it, register it with conditions or refuse registration. The CQC will have a strengthened and extended range of enforcement powers.
- Delegates should inform their boards of the CQC system for judging providers, check their quality assurance framework, consider the evidence that providers already have in place, download the latest guidance from www.cqc.org.uk and contribute to CQC fees consultation.
Quality assurance, Lynn Betts, independent consultant, Quality Governance Ltd
- Quality assurance is a means for delivering cost-effective, efficient, high-quality services.
- Sound quality assurance frameworks are the cornerstone to all good governance systems.
- Quality improvement identifies the gaps between the expectations from healthcare services and the quality of services that are delivered to people.
- The quality measurement journey has seven steps - identifying what we want to measure and how to measure it, clarifying operational definitions, planning to collect data, collecting it, analysing the data and taking action.
Clinical, corporate and information governance, Stuart Emslie, assistant director, Centre for Corporate Governance and Ethics, Birkbeck, University of London, and visiting fellow, Loughborough University Business School
- With at least 44 variations of governance in healthcare, there is confusion in the Department of Health and in the NHS about what governance is.
- Governance is about boards. It is the system by which NHS organisations are directed and controlled. Boards are appointed to govern NHS organisations, not to manage NHS organisations.
- There is a high correlation between board performance and organisational performance.
- Monitor defines clinical governance as management and not governance. Information governance is about handling data.
Integrated governance, Brian Terry, head of integrated governance, NHS Gloucestershire
- Integrated governance is the umbrella for the 44 variations of governance that Stuart Emslie talked about earlier.
- At NHS Gloucestershire, during a recent meeting of the board, five board members with vested interests in a tendering decision were asked to leave the meeting. The register of interests is extended to all band 8a and above managers and the PCT is looking to do the same for independent contractors. The PCT is working to improve relationships with providers. It is developing robust commissioning and procurement procedures. And it has reviewed the groups reporting to the integrated governance committee. Each group fulfils one of four functions - setting quality parameters, reviewing assurances on contracting/procurement, monitoring all contracts and, developing procurement/commissioning procedures.
Board level development, Deborah Arnot, deputy director of organisational development support, NHS North West Leadership Academy, Jay Bevington, director, public sector assurance advisory practice, Deloitte
- The NHS North West Leadership Academy defines leadership as what leaders need to know, what they need to do and what they need to be.
- NHS leaders face challenges in their transition from excellent functional leads to full voting members of NHS boards.
- The Leadership Academy developed three products to address these challenges: the Corporate Directors Checklist, the Board Impact Evaluation Tool and the Governors Effectiveness Tool.
- The Corporate Directors Checklist has four enablers - personal impact, strategic impact (anticipating future consequence and trends), knowledge impact, (being conversant with financial, legal, clinical and commercial issues) and performance impact.
- Evaluation is the driver behind the Board Impact Evaluation Tool. It evaluates the board profile, corporate awareness, the board’s impact on quality, risk and safety, organisational purpose and vision, organisational values, and staff engagement.
- The Governors Effectiveness Tool looks towards enhancing the effectiveness of governors to hold to account, as well as engagement and direction. It assesses information received by governors, the clarity of roles, the leadership of chairs, the committee structure, group dynamics, training and development, support to the council and composition.
PCT governance, Julia Brown, chief operating officer, NHS Enfield community services
- Autonomous provider organisations can improve how they work by developing a new vision, identifying new skills and competencies, upskilling service managers/senior managers/leaders and developing non-executive director and lay board involvement.
- Lessons for autonomous provider organisations: they need to enhance negotiating skills with PCT commissioners, improve patient focus, and ensure their decisions are evidence based.
- Governance structures should be based on the principles of keeping it simple, driving accountability, and ensuring that decisions are made by the right people, at the right time, and in the right forum.
FT governance, Calum Pallister, head of trust practice business, Audit Commission
- Monitor’s compliance framework sets out what it requires from FTs. Foundation trusts are outside the strategic health authority safety net.
- Monitor expects FT boards to be strategic, lean, fit for purpose and have a minimum number of committees.
- FTs need to be clear about their organisational objectives. Objectives should be memorable and tailored to the FT.
- Governors and members represent the public, staff and other stakeholders. Governors can be elected or appointed and have limited legal powers.
- British Petroleum’s perspective on governance is relevant to NHS foundation trusts. In BP’s view, the purpose of governance is to allocate resources to add purpose.
- FT boards of directors are not the main board. FT boards have additional requirements including enhanced financial skills (treasury and managing cash), the importance of non-executive directors and the chair working with governors and the board.
- FT board directors have unitary responsibility for their foundation trust and they cannot delegate to non-voting board members.
Governance between organisations, John Bullivant, director, Good Governance Institute
- NHS organisations must rigorously apply board assurance processes.
- Boards can make more strategic use of independent assurance, including clinical audit.
- Partner organisations need to share commitment and this has implications for board development programmes.
- Boards need to ensure their organisations’ strategic aims and objectives are clearly defined and few in number. They need to ensure that their strategic risks are identified and aligned to their strategic objectives.
- The Board Assurance Prompts identify a series of three or four questions for board members to consider. This is relevant for diabetes, HCAI, dementia, end of life, cancer and others. The prompts provide answers that are plausible and answers that are unacceptable.
- The Good Governance Institute Partnership Decision Tree enables organisations to assess the structural aspects of governance between organisations.
- Its Maturity Index for Governance and Partnership Etiquette entices NHS organisations to be explicit about what is expected from partner organisations.
Patrick Keady is an independent consultant in risk management, governance and safety. He is director at www.betteroutcomes.org and a former NHS trust board director of governance and strategy. Patrick is the first NHS-sourced trustee at IOSH, the world’s largest professional body for chartered safety professionals. He is deputy editor (designate) at RSPHs peer-reviewed Perspectives in Public Health.
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