![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 Daltons 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](https://image.slidesharecdn.com/20a5f7c5-a6f0-44db-a602-37db454d16e7-160716200355/85/Above-Board-2-320.jpg)
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Above Board
- 1. Professor Paul Stanton: Full text HSJ Above Board? Article Innovative forms of inter, trans or supra organisational entities envisaged by the Five Year Forward views 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 snails 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.
- 2. 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 Daltons 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
- 3. 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. 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 entitys 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.
- 4. Paul A Stanton July 2016.