It’s vital that sustainability and transformation plans succeed - and that boards take the job seriously, writes Paul Stanton

Innovative forms of inter, trans or supra organisational entities envisaged by the Five Year Forward View’s whole system transformational agenda raise profound issues for the statutory governance of NHS provider bodies.

For this reason, among others, it is vital that foundation trust/NHS boards understand the necessity and urgency that drive the Sustainability and Transformation initiative and become fully engaged in improving the process itself and in then implementing its outcomes.

England stands on the brink of a demographic catastrophe (compounded by lifestyle factors)

The NHS is already creaking and “there is growing impatience in government at declining levels of performance and frustration at the apparent inability of the NHS and its leaders to turn this around” .The root cause is easy to identify – though not to resolve. It is the coincident impact of austerity and demand escalation. No end to either is in sight.

Instead, England stands on the brink of a demographic catastrophe (compounded by lifestyle factors) where, year on year, need for health and social care provision will rise exponentially and inescapably. By 2032 the number of people in England who are 85 and above will increase by almost 100 per cent. The majority will have complex and co-incident LTCs and will need, in time, end of life provision.

In March 2013, Ready For Ageing (House of Lords Select Committee on Public Service and Demographic Change) demonstrated that “England has an inappropriate model of health and social care to cope with the changing patterns of illness and need in an ageing population”. Shamefully, no political party nor the then NHS leadership admitted or sought to rectify this situation.

Boards must ‘care’ about and for the STP and its implications. Irrespective of its process shortcomings, its intentions are both vital

Good governance

Thus the problem was inherited (but not caused) by the new leadership regimes in NHS England and NHS Improvement. They have (to their credit) attempted to confront a crisis that is already upon us. The urgency with which the system reform agenda has been escalated, in the last year has meant that, in many cases, the STP process has been centrally imposed and executive led.

STPs have bypassed provider boards with the result that, hitherto, most have been interested, concerned or discontented spectators, rather than pro-active players in what is (according to Simon Stevens) the only game in town”. Yet provider boards must have a pivotal role to play. Inescapably, transformative change at system level - what the STP process is designed to initiate - will be impossible to implement without significant, aligned and managed change in the models, patterns and locations of care provided by local FT and NHS bodies.

Boards must ‘care’ about and for the STP and its implications. Irrespective of its process shortcomings, its intentions are both vital (to protect the welfare system and the NHS from terminal financial implosion) and laudable (to improve the fitness for 21st century purpose and the financial resilience of local health and social care systems).

It is for these reasons that its overall intentions merit unqualified support from boards and why the process itself needs to be improved through the intelligent, proactive and supportive intervention of boards, and (in part through them) of the NHS staff community at large.

The new entities envisaged by the Five Year Forward View will need to be robustly and transparently governed.

The highest law

Though it would be inappropriate to attempt, at this stage in their variegated evolution, prescriptively to specify particular governance models (since form should follow function – and the precise functions are, as yet, obscure), it is possible to define key principles of ‘good governance’ that should be embedded (albeit in subtly different ways) in any such new entity. The following need to be explicitly debated and then explicitly incorporated into the governance protocols for any new entity.

As John Carver, correctly, emphasised: “Governance is ownership one level down, not management one level up”

(i) The ethical basis of governance in the public sector should always have been that articulated by Cicero – “salus populi summa lex esto” [“Let the good of the people be the highest law”]. Hitherto, however, boards have been schooled, by government targets and regulatory bodies, to view intra-organisational financial and target performance as the highest and only good. This is, and always was, profoundly mistaken. Boards must, of necessity, maintain a grip on intra-organisational safety, quality and cost but they must in parallel be attentive to complex considerations of overall system-wide cost and effectiveness. 

(ii) The ethical underpinning of this has always been clear. As John Carver, correctly, emphasised: “Governance is ownership one level down, not management one level up”. As the NHS Constitution makes clear: “The NHS belongs to all of us”. It is in our interests, not their own or those of their specific organization, that NHS boards must govern. 

(i) Transparent accountability lies at the heart of the effective exercise of governance. There are always two sides to the ‘accountability’ coin.

There must be explicit clarity, so far as any newly created entity is concerned, in relation to those issue for which it will be accountable. Once this is established it is essential that those charged with the governance of such a body are vested with the determinate authority to discharge their accountable functions.

On the other side of the accountability coin, there must be equal clarity and transparency in the specification of ‘to whom and how’ such a governing board is accountable. Inescapably the answer will be composite.

Starter for 10

There will be, at one and the same time: accountability in law (through civil, perhaps criminal and certainly judicial review processes); accountability to intelligent statutory regulatory bodies; accountability to local citizens in their pivotal position as ‘owners’ (through mechanisms that, frankly, hitherto, have been obscure, non-existent or unfit for purpose).

To what extent such an entity will also have accountability back to the boards of constituent or partner organisations will depend on whether a new entity is supra, trans or inter-organisational and upon the specific nature of such an entity’s own ‘constitution’.

This is no more than a starter for 10. I and other plenary speakers will consider these themes at the NHS Providers Governance Conference on 7 July. 

Professor Paul Stanton is CEO of Southminster Consultancy Associates.