Governance – Wicked Challenges in Healthcare

Healthcare in the U.K. is state-funded and led by way of a political manifest.

Healthcare in the U.K. is state-funded and led by way of a political manifest. The issues of governance in the National Health Service are complicated, and it is a ‘wicked challenge.’  The NHS is one of the largest global employers, with 1.2 million staff members. On average, on any given day, over 1.5 million patient contacts are made with health and care providers in the U.K. The nearest relatable context is Amazon which sends over 1.6 million packages daily. The hierarchical structure, multi-layered bureaucracy, and under-investment in the health system are coupled with crippled capital restrictions and a mountain of workforce issues. This makes for a perfect storm, certainly requiring governance.

In this podcast, Dr Sabine Dembkowski, Founder and Managing Partner of Better Boards, discusses the challenges of boards in the NHS and healthcare with Nabil Jamshed. Nabil is recognised for his outstanding governance work in the largest Trust in the National Health Service in the U.K.  Nabil is Head of Corporate Governance at Guy’s and St Thomas’ NHS Foundation Trust for the Integrated Specialist Medicine Clinical Group. He has over 20 years of experience working in the NHS and internationally with Qatar’s Ministry of Public Health and other health agencies. He is an elected member of the European Health Management Association (EHMA) Scientific Planning Committee, where he contributes to wider European healthcare management developments. He is also a Non-Executive Director at Black Country Healthcare NHS Foundation Trust.

Some of the key takeaways of the conversation include:

“A wicked problem doesn’t equate to a wicked answer”

Nabil explains that health care as a service provided to customers, clients, and patients has grown significantly in complexity over the years due to how communities have grown. Governance within that is what he describes as a really wicked problem, and Nabil thinks solving this is the biggest challenge in the health sector. In the U.K., healthcare is predominantly funded through the state, whereby you pay National Insurance and are provided facilities (mostly free of charge) when you need them. But the traditional model no longer works because we live our lives very differently from how we used to, as our habits, communities, lifestyles, and social constructs have changed. Health and care needs are now two different things, and all the socioeconomic factors known to be significant contributors to a person’s health and care needs must be addressed in a partnership model with robust governance. Defined and clear-cut accountability, responsibility, and rules are needed to deliver the best service to the patients; this is the governance challenge.

“If you don’t take a holistic approach, and take everybody with you on the journey, the governance in the traditional way will fail”

Nabil explains there are many different approaches to governance, and there is still an absolute need for the mechanical aspect of governance – meeting the minimum compliance regime, standards to ensure a safe environment, producing a high-quality product, etc. Committees meet and feed into each other and then to the board. However, governance also needs both a vision and strategy. The decisions taken today need to account for the impact five years down the line, and without that strategic view, you are unable to assess the leadership needs for the delivery of that strategy. You will not be able to understand how you define your risk appetite as a collective unitary board, and the risk appetite determines what to proceed with.

Nabil gives the example that if, 10 or 20 years down the line, a lot of the delivery will be replaced by A.I. or robotics, decision-making today needs to invest heavily in innovation, and a risk appetite needs to be set accordingly, with an open risk appetite for innovation. How do you ensure that the risk appetite is translated? This is what he believes governance is really about.

He feels this is where traditional models fail because they do not emphasise the softer aspects of governance enough and focus more on compliance. Hence, he believes governance has to change and adapt to the new modern governance approach, looking at the cross impact of one area of business to the other and the rest of the organisation in an integrated way. If you do not take a holistic approach, governance in the traditional way will fail because it will not have the support systems it needs.

“Meaningless governance is not governance. Meaningful governance is governance”

Nabil explains that their approach is not typical in the NHS. He gives the example that in London, going from one underground station to another no more than five minutes south, life expectancy reduces by five years with each stop, culminating in a life expectancy gap of about 15 to 20 years. This is a huge problem, and how do you ensure the delivery of comprehensive, holistic health and care needs to address that inequality? Nabil describes that each organisation with a significant role has to think about the basic principles of modern governance, which must be applied and explained.

He explains that his Trust looked at the principles set out by King and his approach to integrated reporting and applied that knowledge in a slightly different way. King talks about his six capitals, but in healthcare, and especially state-funded healthcare in the NHS, their own capitals need to be defined – the key things that make the organisation a success. He gives the example that the Trust cannot compromise the quality and safety of care provided to clients, which is their utmost commitment. This led to how they deliver that through a workforce representative of the population served. Finances are another capital, as are regulatory standards. Without an integrated approach, looking at those individual capitals for the impact assessment holistically on each other, the delivery of care will be pointless.

Nabil believes silos need to be broken to apply and explain governance principles. Ensuring agility is developed within leadership modeling in the vision of delivery of care. This needs to be driven through the frontline to ensure that the clinical people who understand the clinical needs are in leadership positions as the lead accountable people for delivering the services they own. Without doing that, you will have meaningless governance.

“When you have your non-executives involved versus your executives, they have two different lenses”

Nabil relates that executives tend to focus on operational delivery. In contrast, the Non-Executives focus on the assurance that everything is happening as it should happen, with no loopholes, and that this does not expose the organisation to significant risk. In his Trust, they modelled the governance structure on assurance committees and fixated on those capitals. Every committee led on one, two, or a combination of capitals, with responsibility against that. The provision of assurance from the executive committees then goes to the senior board committees. He explains that they have also implemented a performance review meeting process, and joining the two structures together created assurance modelling.

Nabil believes assurance has to be based upon triangulation from various sources, and performance data on key indicators is only one aspect of it. KPIs may give you one aspect, but delivery against the stewardship, modelling, and systemic modelling within the governance is critical. You need to build an assurance model that includes fully comprehensive data elements, softer intelligence from the patients you serve, and what the staff tell you.

“Any single report that comes to the board is aligned to those six capitals”

Nabil advises that the Trust is on a journey that is not yet complete. But all information produced for board packs is now aligned to the six capitals, as is any single report. He is proud of the Triple-A model that has been introduced. Within each report, the 3 A questions are

1. What do we want the committee or the board to be Alerted to?
2. What do we want to provide the board and the committee Assurance with?
3. What Actions are we taking to address going forward?

Every single report that comes to the board covers those three elements. But he notes the real change is in the discussions held at committees in local feeder groups, which is an absolute bottom-up approach. Without a subsidised governance approach, you can’t achieve this right away. They have redefined agendas and enabled executives to hold time for thinking, discussion, and focus of attention before the meeting, so they are pre-prepared about the questions instead of presenting a report. This has changed discussions. This needs both a bottom-up approach and a top-down commitment, plus the mechanical governance combined with looking at the six capitals every time.

He talks about a new discussion place, the Integrated Governance Assurance and Performance meeting, or IGAP, to fill a gap in their thinking ability. This takes all the information from all angles and feeder groups upwards to the executives, giving them that flavour of triangulation of vital themes across the organisation where multiple avenues of leadership structure are affected.

The three top takeaways from our conversation are:

  • Have a clear-cut, long-term strategy; stick to it regardless of changes and believe in the process it will deliver.
  • Build agility in governance and link it to your strategy and the risks you identify through that process, not getting hung up on one compliance only.
  • Complex problems do not mean a complex solution. They mean a simple solution. But that simple solution doesn’t mean the complexities are avoided – you understand and address them and build your governance to simplify those complexities.

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