NHS Trusts are run by Boards composed of Directors, Executive and Non-Executive. In foundation trusts, Non-Execs are appointed by governors, a role transplanted from education. As in education, NHS governors can be either appointed or elected. They can be drawn from the communities who use the service, or from the staff body.
These structures and roles have grand-sounding titles, and many control hundreds of millions of pounds worth of public services. But in a world of unprecedented financial pressures, has the clout been taken out of them?
All too often, pressure to react to resource crisis after resource crisis means that however well-intentioned the people around the table are, there just isn’t time to amass the rich evidence required to look at systems and processes intelligently.
If only some cool-headed time could be found, along with the cool-headed evidence needed to fuel the kind of root and branch discussions that can make systems connect better with the people who use them, millions of pounds of taxpayers’ money could be saved.
As a former BBC employee, who worked as an NHS non-executive director and was an independent convener for complaints, told me, “A lot of talk about quality in the NHS is actually about quantity. The orchestrated reporting of data can begin to ring hollow for NHS boards. There needs to be a way of rooting these discussions.”
A former Patient Experience lead added, “Very often the way the NHS organisation operates is designed for a world that vanished thirty years ago. We’re stuck in a loop. It’s like a computer running old, slow software. We don’t just need to find the keyboard shortcuts. We need to re-program.”
“Facts” as traditionally understood, the formal ones that pepper the paperwork ascending through the system, are part of the old software. New information is required. As a distinguished former NHS Chair revealed to me that he gets “very little assurance from the paperwork that flows upwards”.
So, if some cool-headed time could be found, what kinds of data could inspire the right kind of safe, honest, intelligent conversations, engaging hearts and minds at the same time in way likely to deliver real, money-saving change?
But what kinds of new information?
NHS leaders know in their bones that the information they need is the stuff that bridges “system” and “non-system”. It is information about the way the system they operate connects – or fails to connect – with the day to day lives of the people who use it. And that means "rich data", "crossover data", data that shows how things connect, as well as how they function.
According to the Cabinet Office, billions of pounds a year are wasted as a direct result of ‘disconnect’: millions on drugs that are wasted because people don’t understand what are or how to take them; many more millions on the results of that in terms of avoidable readmissions to hospital, and the resulting stays; and even more millions on people not being able to attend their appointments because the nuts and bolts of their lives mean they can’t.
What would you do if you were suffering from mild depression, had financial anxiety, were expected at Outpatients, and the bus service was unreliable? And who should the conversations be happening with about that? Not the hospital, surely, but the bus company, the CCG, the local Third Sector.
“Storytelling is a powerful way of doing this,” adds my ex-BBC friend. “Complaints, for example, are stories, and community narratives can do that very effectively, but it needs to be done systematically and not just on a whim or in pockets.”
So, stories, including complaints, can, and should, be used in board business; but they need to be woven into the fabric, rather than just sitting, however compellingly, on the surface.
“It’s the opposite of touchy-feely; it’s the ‘how do we know?’ question that every board member should have in their mind and on their lips. The data should challenge the stories; the stories should also challenge the data,” he explains.
In the case of another non-executive, who influenced the improvement of a vital local wheelchair service, the trick was just this: finding the data behind the stories and the stories behind the data. “Data can be true; stories are more than true. They bring a problem to life. ”.
A former lead governor at University College London Hospitals Foundation Trust took a similarly systematic approach there, setting up and chairing a high-quality patient care group for the governors. “The majority of governors have a democratic mandate, but they also need to know what’s happening on the ground. ”
Hearts and Minds
So non-executives and governors need an organisation culture where the heart can be engaged along with the head. “You have to mind when things are wrong; it has to make you angry”, says the ex-BBC non-executive, recalling an “inspired” away day for both non-executive and executive directors where they were walked through the human implications of their decisions.
These are the signals to follow: non-executives and governors armed with the tools they need, where necessary, to “break the spell of the organisation” as another eminent former governor, put it.
Christine Hancock, a leading commentator on global health, who has been a health authority chief executive as well as general secretary of the Royal College of Nursing, told me: “Whatever systems you put in place those systems need a conscience. That might sound a bit flaky to some ears; but you have to ask ‘what makes really busy people stop in their tracks and act swiftly on something that doesn’t fit the accepted picture?’”
Governance needs to be understood experientially as well as structurally. Where both sides are in balance, and with the right rich data, analysed and presented in a way that will drive safe, honest discussion at decision-maker level, the engine of accountability can really sing.
It’s the difference between patients and communities shouting from the sidelines, and all of us pulling together: from patient power to patient powered.