In March 2020, in health systems around the world, major incidents were declared, pandemic plans enacted (where they existed) and swathes of usual elective inpatient and ambulatory care were cancelled, suddenly deemed ‘non-urgent’. Other services such as screening, vaccinations, infertility care, and many diagnostic tests were likewise put on hold, incubating significant trouble for individuals and society a few months or years down the line. In parallel, many organisational meetings, events and diary commitments were cancelled, postponed. As with clinical work, many aspects of usual governance can undoubtedly be put on hold for a while, but there is similarly a risk of storing up trouble for the longer term. This raises important questions about the nature of governance of healthcare organisations in a time of sustained crisis.
For governing bodies of healthcare organisations (in the NHS, the trust or foundation trust board) there is no change to their core statutory duties as a result of the Covid-19 crisis. If anything, the duty to ensure safe and high quality care is heightened, as is that of ensuring that staff are able to work safely and within their range of competence and expertise. Whilst in normal times the duty on healthcare organisations to balance the books can feel to be the most important (albeit in the NHS it has equal statutory weight alongside quality and safety of care), there is a risk in a time of national health emergency of adopting a ‘spend what it takes’ approach to dealing with an emerging crisis. Boards of healthcare organisations remain however the stewards of scarce public funding, and accountability for spending remains vital, both as the crisis is raging, and in due course when a reckoning of costs and benefits is made.
There is a body of research evidence about healthcare governance which remains highly relevant during this pandemic, and we will explore some of the newest insights from such studies in the Health Services Research UK Conference to be held online on 1-3 July 2020. This research underlines the importance of how healthcare boards behave, the values they espouse, and the culture they nurture. It is within this context that each organisation and its board is working out how best to govern its activity, people and services in the context of Covid-19. The Good Governance Institute has used the King Commission report of 2018 to frame advice to boards to focus on: ethical culture; good performance; effective control and legitimacy.
In similar vein, Ed Smith, former Chair of NHS Improvement has written recently of the need for boards to give executives the space to make rapid decisions and feel supported in so doing, with ready access to advice. He also proposes a role for non-executive directors in noting changes made as a result of crisis that should be preserved longer term, and leading thinking about how the organisation will exit the crisis phase, and plan for a ‘new normal’ beyond the extended major incident phase.
For healthcare organisations steering a course through and beyond these turbulent times, research that Professor Naomi Chambers led (and in which I was a co-investigator) for the National Institute of Research over the period 2015-2018, examining how hospital boards had responded to the findings of the Francis Inquiry into the events at the Mid-Staffordshire NHS Foundation Trust is highly relevant. We articulated five roles for a healthcare board, two of which seem particularly pertinent to the Covid-19 response.
First, the board as conscience of the organisation ‘leading the development of a core set of values, deliberative and inclusive approaches to making priority-setting decisions, and using listening and questioning behaviours’ (Chambers et al, 2020, p104). This may entail determining a values-based framework for how best to decide what services to cease or postpone, what level of delay or harm is acceptable as a result of these decisions, and whether and how to offer mutual aid to other healthcare providers (as this may compromise the services and staff of the organisation).
Second, the board as coach to the leadership team and wider organisation, which in a paper published just a few weeks ago we asserted was necessary in ‘the turbulent times we observed in our study’ – little did we know how much more turbulent life in the NHS was to shortly become. This role is concerned with the board (and in particular non-executive directors) setting direction, providing support and challenge, and doing so in an enquiring and supportive manner which is perceived by executive directors as helpful and constructive. Achieving this with appropriate nuance, respect and support in a time of extreme pressure is perhaps the greatest challenge to those currently involved in healthcare governance.
In this time of crisis, perhaps more than anything, healthcare boards must ensure they set a compassionate tone and support an enabling and healthy organisational culture. They would do well to heed research undertaken recently by Julia Unwin for the Carnegie Trust on kindness in public policy:
‘And at times of vulnerability and weakness, just the time at which most of us experience public services, our need for a kind, human and emotionally astute response is always greatest. […] That’s why kindness is so disruptive. It changes the relationships between people, and inevitably demands a change in the relationships between people and institutions and organisations.’