While their Lordships sweated over amendments to the the bells and whistles juggernaut that is the Health and Social Care Bill, in another part of the Westminster Village, Chair-designate at the National Commissioning Board (NCB), Prof Malcolm Grant, told the Health Select Committee’s pre appointment hearing precisely nothing about his intended approach to patient and public involvement. That’s a pity and a lost opportunity to send a signal to the Clinical Commissioning Groups (CCGs) about what they should be doing about their own local involvement strategies.
We don’t have the NCB in place yet – and it won’t be fully operational until 2013 – but we need it right now. Too many cart-before-horse changes can happen locally in the interim that are not in the interests of users or the public. If the NCB’s new chair isn’t clear about its role and relationships, we should be worrying.
Confused or just wrong – it amounts to the same thing.
He ignored involvement, but Prof Grant did say something quite astonishing about governance and management. He asserted to Stephen Dorrell and the members: “ It is absolutely critical to be clear about the difference between governance and management. David Nicholson will have responsibility for managing the Board. The Board will have responsibility for governing.”
Quite so. Clarity on this is essential. But clarity isn’t what he gave us. “Responsibility for governing what?” and “Governing in whose interests?” are the big unanswered questions. If Prof Grant really thinks the role of the Commissioning Board’s CEO is “managing the board”, then he might as well give “Big Beast” David Nicholson the boardroom keys now and be done with it, because the non-executive board members won’t get back in the driving seat once Nicholson and his executive team are up to speed.
If this is just a terminological confusion and what Prof Grant really meant to say was that Sir David would be “managing the work of the Board” that’s a different matter. But we were left none the wiser about his intended meaning at the end of his appearance in front of the committee. And that is worrying in one about to take on such a key role.
If a CEO – any CEO – ends up “managing the Board”, then why have a chair and non-executive directors and their associated costs in the first place? Boards must not be fig leaves or rubber stamps. And they are not – write this out 100 times – the top tier of management.
Prof Grant claims to want clarity about governance and management. He should include in the list that key concept in healthcare – “ownership” – because that would help get things into focus. Who are the owners of the NHS in England that the Board is acting for? Starting to think about this with Caroline Oliver’s essay on the subject would be a good idea.
The answer is that the Board of the NCB must govern in the interests of the people of England who are the moral owners of the NHS in England. Boards are there to represent the interests of the owners. We have posed in many ways and in many places the key question: “Whose NHS is it anyway?” The answer is “not David Nicholson’s or Andrew Lansley’s or even Professor Grant’s”.
Mandate and deliverables
The mandate the Board will receive from the Secretary of State every 2-3 years is about deliverables and outcomes. This is a radical process and Prof. Grant’s views on what it means for accountability are illuminating. As he told the Health Committee in widely reported terms:
[what] that does is effect an extraordinary transformation of responsibility within the NHS. … It is passing over the responsibility and then allowing the Secretary of State, through the mandate, to hold the Board accountable against the objectives that have been set for it. It is then for the Board, through its relationship with the clinical commissioning groups, to hold them accountable for the objectives that are set for them. It allows us, for the first time, the possibility of tracking accountability and responsibility through a system and, what I would see as being the prize to fight for, restoring to the NHS the stability that it needs away from day-to-day political interference in its priorities. You may worry about the ultimate political accountability. It remains secure, but it requires a Secretary of State to define upfront what he or she wants the Board to be accountable for and to hold the Board accountable for it.
In other words, how the NCB carries out the mandate should be up to them and their formative relationships with the myriad CCGs, without feeling the hot breath of Ministers on their collective necks. The Board members will not manage this complex task themselves, of course, but delegate to the CEO and his executive team the necessary authority to achieve the mandate’s deliverables on their behalf (which means on our behalf of course), monitoring performance and holding Nicholson to account.
Governing on our behalf
The Lords can accept as many amendments as they wish to what Prof Grant has already termed an “unintelligible” bill, underlining the ultimate responsibility of the Secretary of State to provide a health service in England. That is about accountability to Parliament. It does not change the moral ownership relationship of the public to the NHS and the accountability of the NCB Chair and Non Executives to govern on our behalf.
The message Prof Grant has to hear is this: The Board of the NCB must act (govern) on our behalf as the moral owners. If the NCB does not do this, the default is that centralised bureaucratic control in the shape of the Big Beast and the executive directors will end up pulling the NCB’s strings.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.