Governing an NHS trust is one of the most challenging tasks I have encountered in a working life that has spanned private industry, local government, the voluntary sector, universities and the European Union.
Over the last few years, I have had the privilege of working with the boards of NHS trusts on a daily basis. I have been impressed by the resilience and dedication that so many board members, non-executive and executive alike, demonstrate in the face of seemingly insurmountable difficulties.
On 1 April, the Clinical Governance Support Team, where I led the work with NHS boards, closed. I am, thus, no longer a "part of the system". So I will attempt to use the luxury of a more remote perspective to reflect honestly on the nature and origin of the difficulties NHS directors face and consider how best these might be addressed.
In other words, I am now at liberty to question whether the NHS emperor really is wearing new clothes and can even cast a critical eye on an unhealthy paunch or a skinny calf.
A closer look
In the coming months, I will explore the nature of the public sector governance task itself. In my experience, there continues to be widespread confusion and misunderstanding of "governance" in the Department of Health and in senior echelons of the NHS. Unless the function of governance is understood, its forms will always be (at best) sub-optimal and (at worst) abjectly ineffective.
I will consider whether an NHS board really has the authority and autonomy it needs to discharge its statutory duties and its ethical responsibilities to local communities.
I will attempt to clarify misunderstanding in relation to public sector governance and to make explicit the differentiation that should exist between a board's governance function and a trust's leadership, management, operational and clinical performance. How a particular board performs its governance function will have a critical bearing on these vital aspects of a trust's function, life and contribution to the public good - but the relationship is a mediate (and not an immediate) one in terms of both role and time.
I will explore the commonalities and differences that exist between executive and non-executive board members. In order to work as a high-performing corporate entity, each of these groups needs to develop explicit clarity in relation to the distinctive (but complementary) contribution that each of them should make. They also need to consider how inescapable differences in perspective and function can best be explicitly identified and managed so that they become a source of creative tension rather than debilitating and arid conflict.
Only where boards confront these issues honestly and forthrightly can reciprocal informed trust develop within them.
I would like to begin, however, in the first of this series of columns, with a more fundamental consideration of the NHS and its contribution to UK society. I believe it to be one of the great civilising legacies bequeathed to the new century from the last.
Beveridge, Bevan and others of that great generation of social progressives were able, in the darkest days of the Second World War, to create and sustain a vision of a more just and equitable social order. More importantly, they were able to translate this vision into reality so that on 6 July 1948 the NHS was officially born. For those of my generation, the Baby Boomers, its lifetime has been coterminous with our own.
In many respects, it is a proud achievement. Set against international comparators, the NHS has fundamental strengths. The "lowest common denominator" of universal care that it provides to all citizens is higher than that achieved by any system in the developed world (see the conclusions reached recently by the Commonwealth Institute in the States - no reflexive supporter of publicly funded state provision).
While it is true that, in relation to any specific clinical condition, it is generally possible to identify a system somewhere in the world that performs significantly better (that is, which has a condition specific "higher common factor" than the NHS) none provides either the overall value for money or (almost) universal access to clinical care at the point of need that we have enjoyed, uninterrupted, for the last 60 years.
And this despite the political, economic, social, structural and ecological turbulence that characterised the second half of the last century - and seem set to become accelerative hallmarks of the new landscape of need and of care.
Herein lies one of the great challenges that confronts the NHS and other public services and those who govern them. The world in which the NHS will celebrate its centenary in July 2048 will be profoundly different, in so many respects, from the world in which the NHS evolved and which shaped its current form. In order to remain relevant and fit for so different a future, the NHS needs, as of now, to develop flexible adaptive capability and to reconceptualise how best to deploy its capacity - in human, fiscal and estate terms.
In other words, those who govern the system and its organisational parts need to look forward - not merely (and despite the short-term nature of so many of the demands made on them) to remain pre-occupied with this year's targets, performance and fiscal outturn.
This is less an agenda of reform than it is of constant organic (r)evolution. However, challenging the governance of a steady state system may once have been, the governance of an organic, adaptive and evolutionary one is infinitely more complex. It demands value-based principles, scientifically informed knowledge and creatively nurtured artistry.
It is important to recognise that, even in terms of current demand and expectation, the NHS is still running to catch up. Decades of underinvestment require decades of corrective action if need and resource are to be brought back into sustainable balance.
A service that has been focused on the management of the burden of current illness and disease is not easily or quickly transformed into one whose core business is the promotion of health and well-being. And a culture that has been required to put the needs of service users second to the demands of its (successive) political masters is, not surprisingly, struggling to translate patient-centred care from facile rhetoric into a lived reality for patients and staff alike.
This brings us to one of the deep paradoxes of the NHS. Overwhelmingly, it is comprised of individual frontline staff, clinicians, managers, administrators, executives and NEDS who do care about those who are in need.
Overwhelmingly, all of these groups and individuals set out to do the best job that they are able. Yet, far too often, we fail our patients and their immediate carers. Far too many who turn to the NHS (often in extreme need) find their contact with the system to be problematic, impersonal and demeaning. The system itself seems to behave as the impersonal and tyrannical master of individual human need - not a flexible servant of it.
In other words, inhumanity has become a deep "system property". If we are ever effectively to counteract and reverse this inhumanity, it is important that we understand the complex historical and other interactive forces of which it is an (unintended) product.
It is these forces that I, together with many other colleagues, intend to seek to overcome through the creation of the Humanising Healthcare movement. I will explore and expand on this movement and these issues in the next of this series of articles. In the meantime, I would be delighted to hear from NEDs and others in relation to these issues.
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