Accountability in healthcare

We are in exciting times – clinical commissioning groups (CCGs) are emerging and developing to become commissioning organisations. These new organisations will be well placed to improve the outcomes in the NHS.

However it is crucial that we now spend some time reflecting upon how we ensure the foundations of our new organisations are secure. We have an opportunity, not afforded to most, to design supportive governance structures that will help organisations to safely discharge their duties.

The word 'governance' has a very long history; it is derived from the Greek verb 'to steer' and can be traced all the way back to Plato. Governance initially developed as the ownership and management of organisations began to separate; consequently systems started to evolve to ensure that the interests of the owners were protected from detrimental managerial actions.

All organisations are aware of the need for sound governance, yet the long shadows of governance failures have all too frequently darkened corporate history, be they in the banking, health or industrial sector; sadly they are all too prevalent.

Much has been written on good governance with one of the most important frameworks for the public sector being the Nolan Principles. These seven principles: selflessness, integrity, objectivity, accountability, openness, honesty and leadership describe how those of us in public service should discharge our duties.  

These are the seven values we should espouse. Many will live by these principles and we all recognise their importance. However, how do we ensure that these principles are replicated in the way our organisations undertake their business? It is crucial that such an important part of our organisational design is not left to chance.

Governance – at the heart of an organisation's DNA
Clinicians have a deep understanding of the importance of clinical governance and this has been developed immeasurably over recent decades but the light of governance must shine in all the areas of our work – be they corporate or clinical, or in the management of information.

All too frequently governance is mentioned as an afterthought, rather than an organisational foundation. Governance is far more than a passive noun and it must become part of our organisational DNA.

The elements of effective governance are multiple. Most organisations start with the development of a clear vision, enabling the members of the organisation and external partners to be clearly aware of their direction. To deliver the vision there needs to be a carefully thought-out strategy, that is then translated into a plan of action.

Assurance is a central part of governance. This enables the organisation to gauge if it is delivering its strategy. The assurance process must determine what the risks are, be they service risks or financial risks and enable the organisation to develop plans to manage those risks, should they arise.

Stewardship is an important aspect of governance in order that there are effective decision-making processes, and protective checks and balances to ensure the sound use of the organisational resources.

Finally, it is crucial that the organisation discharges its functions within acceptable standards of conduct and acts in an open and transparent manner; it needs to demonstrate probity. 

Governance is not merely confined internally within an organsiation and careful thought must given to how effective structures can support partnerships between different organisations.

There is no one-size-fits-all; and indeed governance must be more than just a structure or a set of processes. The principles of sound governance must reside within the culture of the organisation.

The issues surrounding governance within the newly defined CCGs were explored in detail in a recent publication by The Kings Fund.  

Additionally, the Good Governance Institute is a very useful resource in these matters. 

Sound organisational governance will provide the foundation on which to develop high-performing organisations that are able to demonstrate good stewardship of public money.

The Author
Dr Paul Zollinger-Read medical adviser and lead on primary care, The King's Fund




This article was first published in the Accountability issue of the New Health Strategies series. The interactive digital version of the issue features additional video content, links to an array of key documents and insights from all sides of the debate – to view or download it click here.