The best boards are where the debate involves all the players,
is messy but retains a sense of form

What's the difference between transformation and governance?

I often hear that health services today need transformational leadership. There are some good reasons for this. Whatever progress we make in acute services there remains a gap between how far we've come and what the public,
and sometimes our patients, think about us.

While the best of the service industry develops direct-line, personal banking and internet-based solutions to customer needs we continue to offer complex service models with built-in delays and a high risk of breakdown. But we are not a simple hierarchy.

In even the smallest acute hospital there may be scores of separately recognisable professions through which the patient passes on his or her journey. And many of these professions have a long history of independence, including the employer (which anyway keeps changing its name).

So how does transformational leadership work in complex professionalised organisations? When I hear this phrase my mind turns to Delacroix's picture of Liberty on the Barricades, exhorting the revolutionaries to charge. I can't see this working in acute services. However good the story we have to tell as boards and chief executives, however engaging we are as personalities, and even with authority derived from our years with the trust, there has to be substance.

My view is that comes from governance. I don't mean 'good old-fashioned governance'. I think governance is really rather new. I remember a medical school dean being exhorted by a colleague to make a particular investment on the grounds that 'it's a drop in the ocean.' 'Yes,' he replied. 'But the ocean is made up of a lot of drops.'. How good have we been at identifying and managing the drops? Or have they grown into something of an ocean? It's difficult to do transformational leadership while finding oneself in King Cnut's position.

Corporate governance literature abounds these days - from reports on board working and composition through to concepts of integrated governance (with the odd challenge from ideas such as 'slim governance'). So we should be clear on the anatomy of governance - the bits we should have in place. I suspect every trust can show us a comprehensive organisation chart. But can we demonstrate the physiology?

Where do the clinical, financial and people bits come together and get traded off? How well does the board work together? How good is its information base? How does it call its constituencies to account? Does it have a strategy based on an understanding of its position or a collection of wishful thinking? Can it demonstrate investment in the workforce? Can it demonstrate an investment in innovation?

I heard recently that one acute trust board has only just understood the extent of its financial problem because the chief executive and chair were keen to present a positive picture - in spite of the need for cash borrowings in excess of 50 per cent of turnover! In boards and other parts of our committee structure there is a risk of what you might call a 'not-meeting', where the participants elect not to discuss key issues even of impending disaster.

The best boards are where the debate involves all the players, is messy but retains a sense of form and purpose, because there is trust. To quote the philosopher David Hume, 'truth arises from disagreement amongst friends'.

If the friends are prepared to disagree and debate it is imperative that discussion is based on sound evidence. I've talked before about King's activity-based costing system, the move to trading accounts, and how that persuades many in the trust to join in the governance process. I may not have mentioned that a large part of the King's First Choice programme is about establishing genuine performance data, agreeing metrics and fixing lines of accountability. We're not taking people over the barricades so much as giving them the tools to do a sound clinical and managerial job.

We are far from alone. I think it's been easier in the past to allege avoidance behaviour - 'the figures are wrong' - than to recognise that the figures actually are wrong. After all, witness how a clinician when pursuing a project will create his or her own database.

How many trust strategy documents are explicit about what services they will shrink or get out of? This interests me because in the current policy environment, that is one of the few certainties for NHS-provided acute services. The key issue is how long the process will take.

The danger for boards is we continue to undertake strategy as a shopping list, or, even worse, strategy as the new hospital. If we don't deliberate properly on strategy we cannot expect to lead opinion towards change.

Given the need for change what building blocks do we have for innovation? I notice that many of the successful foundation trusts are strong in training and development. This ranges from sophisticated induction processes for new entrants into the organisation to opening career doors for staff some way down the ladder (such as the Learning Zone at King's).

The same trusts appear to invest in change activities and teams as part of their regular business. When trying to persuade the Pope to give him a commission, renaissance artist Benvenuto Cellini said, 'cats of a good breed mouse better when fat than starving.' We too have to give our people a bit of support if we want them to come up with ideas.

So if we have the anatomy and the physiology of governance my guess is we can achieve quite a transformation. It strikes me as a much better deal than asking weary troops to climb the barricades one more time. -

Malcolm Lowe Lauri is chief executive of King's College Hospital foundation trust.