Wanted: new model of governance

20 November 2015

By Julian Patterson

Asked to identify the biggest obstacle in the way of the Five Year Forward View, people will give a range of answers likely to include funding, payment arrangements, workforce, the procurement rules and politics. All of these can be fixed or worked around.

What you won’t hear people say so often is that governance is the critical factor in ensuring the future of the NHS, and should be a top priority of the architects of so-called new care models. Never mind the low-profile wheels and the go-faster stripes, without governance it’s going nowhere.

According to the dictionary, governance is the “action or manner of governing a state or organisation”. It also has an archaic meaning: “control”. In the NHS we still tend to favour the latter definition.
 
Another definition – traditionalists will like this too – is that governance is the “establishment of policies and continuous monitoring of their implementation by members of the governing body”.
 
While that describes what governance is, it also makes it easy to forget what governance is for, inviting us to think of it as an end in itself, a set of inward-looking processes and self-validating rules mainly designed to protect the organisation from its mistakes.
 
If this definition was good enough, providers would be sanguine about CQC visits and the other externally sanctioned processes that test their governance. The fact that they are not (and that so many organisations fail these tests) points to a problem.
 
A recent survey of 200 healthcare leaders published by the HSJ examined attitudes to quality governance. It found only a third of organisations confident that their governance arrangements would protect them from nasty surprises when, for example, the inspector calls, and only around half thought that their processes yielded any useful insights or information.
 
Yet most thought their quality strategy was “core” to their business and “fully aligned” to their organisation’s needs.
 
The obsession of boards with what they can or cannot control is at the heart of most governance failures. It may be counterintuitive, but this kind of governance usually puts control out of reach. Mid Staffs was a governance failure with tragic consequences. The formal processes of governance were fine, but everything else was failing. Boards that define ownership of the problem as keeping it to themselves will continue to make similar errors of judgement.
 
On the issue of quality, Simon Dowse, director of BDO, the company that produced the survey quoted by the HSJ, said “Our experience of working with organisations on quality governance systems and processes shows that they often also fail to recognise and tap into the earnest desire of staff to get it right” – a sentence that could have been written for Mid Staffs.
 
Too often, governance is a hygiene factor or the first line of defence in a crisis. Governance is what the board does to stop things going wrong, not what it does to make sure they go right.
 
Engagement with customers is important, so is engagement with staff. They don’t “deliver” your organisation’s quality, they are the quality. The HSJ survey found too few directors thought their staff were “engaged in quality governance” but this is missing the point too. You don’t engage staff in governance but for governance. Engaged staff have a better understanding of what the organisation is trying to do and a bigger personal stake in ensuring it happens. An engaged organisation has less need of formal governance arrangements; they cease to matter.
 
Governance is not about structures, policies or RAG reports, but about culture and behaviour. Good processes are important but they depend critically on good engagement with staff and customers. The former are the governance field force, the latter are your only truly reliable source of assurance, evaluation and improvement.
 
If quality and safety are the biggest causes of anxiety in the boardroom, conflict of interest is not far behind. CCGs are tying themselves in knots to avoid the PR pitfalls of conflict of interest, but they are a vital ingredient of successful GP led commissioning: without conflict there is no interest.
 
There will be times when it makes most sense for clinical commissioning organisations to commission services from their GP members and times when this is most certainly not the case. These decisions need to be accountable and justified, not avoided at all costs. The job of governance is not to eliminate conflict of interest but to keep it alive and manage it well. For everything else we have block contracts and monopolies.
 
Here is one more definition of governance, this time from Wikipedia, the repository of popular wisdom: “All processes of governing, whether undertaken by a government, market or network, whether over a family, tribe, formal or informal organisation or territory and whether through laws, norms, power or language.”
 
Some people may find that uncomfortably loose. For others, avoidance of a narrow set of rules and procedures, and busting the myth of control at all costs are necessary freedoms.
 
Julian Patterson is a director of PCC. Contact him at julian.patterson@pcc.nhs.uk
 
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