Professor Paul Stanton: Full text HSJ ‘Above Board?’ Article

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, amongst others, it is vital that FT/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.

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” (Chris Ham, 16.06.16 http://www.kingsfund.org.uk/blog/2016/06/three-versions-nhs).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 life style 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%. 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 & need in an ageing population” . Shamefully, no political party nor the then

NHS leadership admitted or sought to rectify this situation.

Thus the problem was inherited (but not caused) by the new leadership regimes in NHSE and

NHSI. 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 (not least

because of the snail’s pace of collaborative and transformative locally initiated action since the

publication of the Five Year Forward View) has meant that, in many cases, the STP process has

been centrally imposed and Executive led. STPs have by-passed 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 Stephens) “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 – whether they are predominantly acute, specialist, community, Mental Health or

Ambulance service providers.

It is all too easy to be critical of many elements of the STP process: STP development has been

‘led’ but it has not been ‘governed’; many STPs appear to be cost reduction rather than ‘fit for

future purpose’ driven – as if sustainability can be achieved purely by improved short term cost

reduction; the fact that few STPs actually derive from a comprehensive Public Health analysis of

current and future need; the failure adequately to incorporate or at least pay heed to the

statutory duties of public and patient involvement; the lack of radical re-consideration of the role

of General Practice; the absence of proactive involvement of clinical networks, senior clinicians

and front line staff in deliberations and option appraisal; and of course the fact that most STPs

have failed to draw upon the insights and wisdom of, not least, the NED members of provider

Boards). It is little wonder that an STP director, Amanda Doyle, told the NHS Confederation

Conference that it was like being “a parent of small children… no one pays any attention to

anything you say, and you do it because you care, not because anyone ever says thank you”.

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, pro-active and supportive intervention of Boards, and (in part

through them) of the NHS staff community at large – lest “old-style performance management

takes precedence over change being led from within the NHS” (Ham, 16.06.16

http://www.kingsfund.org.uk/blog/2016/06/three-versions-nhs)

Above Board?

The new entities envisaged by the Five Year Forward view will need to be robustly and

transparently governed – a fact emphasised by Sir David Dalton’s reflections on the evolution of

‘hospital chains’ – “a ‘chain’ is created when two or more ’groups’ of geographically associated

organisations are incorporated under common governance arrangements…. The startup of a new

form of governance needs careful consideration and will take time” (Dalton HSJ 22.6.16).

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 and explicitly incorporated into the governance

protocols for any new entity.

(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 Board’s 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. Their response to (evidence based) STP

outcomes must be based upon the key principle of ‘organisational altruism’

(ii) The ethical underpinning of this has always been clear. As John Carver, correctly,

emphasized “Governance is ownership one level down, not management one level up”

(The Principles of Policy Governance, 2006). As the NHS Constitution makes clear “The

NHS belongs to all of us”. In other words, collectively as citizens, we own the NHS. It

is in our interests, not their own or those of their specific organization, that NHS

Boards must govern. “What is important is that the interest of the population is put

ahead of the self interest and preservation of organisations.” (Dalton HSJ 22.6.16).

(i) Transparent accountability lies at the heart of the effective exercise of governance.

There are always two sides to the ‘accountability’ coin.

a. 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.

b. 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. 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

(who must develop metrics that measure and validate the whole system impact of

the performance of such entities and their constituent parts); accountability to

local citizens in their pivotal position as ‘owners’ (through mechanisms that,

frankly, hitherto, have been obscure, non-existent or unfit for purpose).

c. 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 ten. I and other plenary speakers will consider these themes at

the NHS Providers Governance Conference on 7th July. I am also working with the Kings Fund to

create a development programme for Chairs and NED Board members who wish to ensure that

their Boards are fully involved with the Sustainability and Transformation process and shape,

alongside and on behalf of their local communities, innovative models of care that are expertly

governed.

Paul A Stanton July 2016.