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NHS governance arrangements evolving but not at the pace required to sustain quality...

...and financial balance

Leading business and financial adviser Grant Thornton UK LLP, today publishes the findings of its third annual NHS governance review. The 2014 review, entitled Staying in the Saddle, explores the established governance standards of trusts and effectiveness of the newly introduced clinical commissioning groups (CCGs).

The review finds that despite a number of NHS organisations making good progress on governance, many are yet to adopt the full suite of measures necessary to navigate the current structural changes affecting the public healthcare system. The authors suggest that further progress is needed to realise the potential of  trusts and CCGs, and enhance public confidence in their effectiveness..

The report identifies a number of key concerns in relation to governance best-practice across the NHS, broadly grouped in the areas of:

Leadership and culture: the report suggests a need for stronger leadership in the sector, as less than half of trusts surveyed believed their chair sets the tone from the top for governance. Less than a quarter (23%) of CCGs believed general practitioners (GPs) set the tone for governance under the new GP-led commissioning arrangements. Additionally, 42% of trusts felt governors under their new roles and responsibilities did not effectively hold boards to account.

Governing commissioning and collaboration: despite being in operation for less than a year, 89% of CCGs felt they made good use of collaboration and are working to develop stronger working relationships with other bodies – particularly local authorities. The management of conflicts of interest remains a concern, with three quarters (75%) of CCG respondents agreeing this represents a significant risk.  Reassuringly, 90% of CCG websites contained appropriate and transparent conflict of interest disclosures; although 75% of these were not updated regularly.  

Quality and financial governance balance: The reports states that the £30 billion of savings needed over the next seven years will inevitably create a tension between financial resilience and care quality, which will need to be managed through more robust quality and financial governance arrangements. 42% of CCGs and a fifth (21%) of trusts had concerns about the quality of data supporting their decisions. Nearly all trusts felt their board was assured that efficiency programmes were not lowering the quality of patient care; however, 41% of CCGs said they had not yet undertaken comprehensive clinically-led quality impact assessments of all their trust provider cost improvement programmes (CIPs).

Accountability and transparency: a common thread running through the recent Francis Report and Berwick and Keogh reviews of the NHS was the need to engage more with staff, patients, carers and families. The analysis suggests that, in light of increasing regulatory requirements driving the length and content of annual reports, the risk of annual reports becoming mere compliance measures has increased, potentially diminishing their usefulness as key stakeholder communication vehicles.

Commenting on the report's findings, Bill Upton, Partner and Head of Public Healthcare at Grant Thornton UK LLP, said: "Effective governance is a vital component to instilling confidence in the public healthcare system – both from its employees and the public using these services. Structural changes in the sector, coupled with ever-increasing quality demands and financial constraints, mean that the requirement for robust and transparent governance frameworks has never been greater.

"We've seen some positive progress across the NHS over recent years, but the evolving structural and cultural landscape in which it operates requires the public health system to be at the cutting edge of good governance; which at the moment, is not the case. More needs to be done to ultimately ensure the system improves in line with public expectations, without jeopardising the quality of patient care."

The review by Grant Thornton UK LLP is part of a comprehensive annual analysis of corporate governance amongst the FTSE 350, local government, charities, social housing and the NHS.