The role of boards in setting and nurturing a positive organisational culture is now rightly recognised as being of central importance. Culture, or ‘how we do things here’, is not something that can be imposed remotely from the centre or be the subject of regulatory diktat. West et al identified the strongest predictor of mortality rates in acute trusts is "the percentage of staff working in well structured teams that have clear objectives, that meet regularly to review their performance and how it could be improved, and whose members work closely and effectively together" (NHS Staff Management and Health Service Quality). Fostering a culture where teamwork, appraisal and problem-sharing and solving are part and parcel of the way of working can only happen in a climate in which trust and candour are the norm. This is only possible where there is close interaction between an organisation’s leaders and those they lead.
Trust and candour are essential if people are to speak up about problems as they arise so that they can be dealt with rather than hidden or ignored. Good boards depend on this to help them identify problems and address them. Mary Dixon-Woods, professor of medical sociology at Leicester University, describes this as ‘problem-sensing behaviour’. She expresses concern that the demands of regulators and central organisations, rather than facilitating positive behaviour, might actually inhibit the delivery of quality healthcare: "If the provider system remains too focused on servicing external accountability demands and protecting providers' own reputations, they may be disincentivised to find bad news. This can easily divert providers from problem-sensing behaviour – looking for bad news (including fugitive knowledge) and instead incentivising 'comfort-seeking" (NHS Providers, 2015).
Boards are able to do what the centre and regulators cannot conceivably do from an outside perspective because they can harness high-quality information from multiple sources, triangulate and obtain assurance based on sufficient evidence. The regulatory frameworks, by way of contrast, often look to performance management as a proxy for governance. Performance management at best produces compliance, however, prioritising compliance can skew priorities away from what is necessary to deliver for patients and towards what is necessary to keep the regulator onside. It also makes whatever is measured important, rather than measuring what is important.
So, if performance is prioritised, where does that leave those aspects of quality that are best described using softer information?
A key role for boards of directors in delivering quality services is to put in place processes to control risk (or uncertainty of outcome), and to seek and obtain assurance (that is, confidence backed by sufficient evidence). Boards look for solid evidence that the outcomes they seek are being achieved and, perhaps most importantly, they look to identify gaps in controls and take action to ensure those gaps are treated effectively. They do this by:
- knowing their organisation and how it operates, tailoring risk management processes to local circumstances, overseeing the work of and challenging the executive to ensure that what is presented as evidence is not taken at face value and that the full range of explanations for outcomes is explored
- testing this through triangulation – testing what they have heard against what they see within the organisation and what they hear when they speak to staff and those who use services
- seeking to verify what they believe they know about their organisation through deep dives, audit, peer review and external reviews, among other methodologies, so that they can improve the quality of assurance they receive.
It is this, the quality of assurance, not performance data, periodic inspection or proxies for governance that is likely to speak most loudly on the quality of services. It is axiomatic that board assurance requires local boards of directors.
The nature of NHS trust and foundation trust non-executives has changed radically over the last decade. The foundation trust and NHS trust board is now a place for non-executives who bring significant business and other skills to the table. It is a place for a real independent perspective made on behalf of the public and populated by people who can inject real challenge into board debate so that executive directors are really held to account. It is therefore no coincidence that there has been a real change in the way NEDs are regarded, in what is asked of them, and in the support and development opportunities available to them. A good board is the first line of accountability and regulation, and the one most likely to be effective in dealing with problems before they become a real issue, rather than insisting things are put right after the event.