Comment / Assured delivery

Why on earth would anyone want to be a member, or more particularly the chair, of an audit committee in an NHS provider today?

These organisations manage huge risks day-in and day-out with a workforce that is under immense pressure. They are part of an ever-changing NHS that creates huge governance challenges – like those created most recently by the creation of 44 sustainability and transformation plan footprints.

And you can add in the growing reliance on IT systems and data management and the threats of cyber-crime. All in all, managing the audit committee and ensuring assurances are in place that these risks are being controlled becomes a pretty daunting task.

The answer, of course, is the other side of the same coin. The reason people want to be on an audit committee or even chair one in the NHS is exactly because it is a hugely responsible role. And as a common attribute of all non-executive directors is the desire to ‘put something back in’, then, by definition, the higher the responsibility, the more you can put back and the bigger the impact.

Frontline roles in the NHS – dealing with patients – are obviously fundamental to delivering good quality healthcare. But getting the infrastructure, systems, accountability and governance right (and giving assurances to the board that these are all working and fit for purpose) are also vital. This is what allows those on the frontline to do their job as effectively and efficiently as possible. Good healthcare is built on sound governance.

The NHS is recognised by many as the most efficient health system in the developed world – as shown in the Commonwealth Fund 2014 report comparing healthcare systems Mirror, mirror on the wall. The comparison of 11 healthcare systems in the Western World, put the UK top for efficiency (and incidentally virtually every other measure). By comparison the US came last.

At the heart of this efficiency are clear structures and accountability and transparent governance. I believe this is one of the secrets of the success of the NHS. Despite constant change there has always been a focus, maybe even obsession, on getting the governance right.

This is a huge challenge in such a large, diverse and complex public body. And there are always opportunities to improve. When things go wrong, we certainly get to hear about it – and quite right too – and in most cases that leads to further tightening of controls.

The determination to improve accountability and lines of reporting is something every audit chair is very aware of – ensuring that, as systems change, the governance arrangements change to support new arrangements.

The creation of 44 STP footprints is a current example. There is a clear need and vision for the approach – taking a local health system view rather than a simple organisational focus. But we are only just beginning to understand the governance arrangements that will be needed to ensure systems retain control.

The issues around STP governance were explored in a workshop run by HFMA and the Nuffield Trust earlier this year. There was a worry that the current governance structures are not clear enough, leading to confusion over responsibilities and conflicting loyalties. This in turn could lead to unclear decision-making and conflicts of interest for those tasked with making decisions.

The implication of properly functioning STP footprints is that executives on an STP board may take decisions that might be good for the STP, but have some negative impact on their specific organisation. If this is going to work, then the regulatory system – which remains predominantly focused on organisational performance – may also need to be reviewed.

Audit committees will be at the very centre of these issues – helping to understand how governance frameworks can work at both organisation and health system levels.

Given the size of the agenda – and the importance of developing new models of more integrated care – we need our best people at the helm of these audit committees.  It is a demanding but hugely exciting position, so perhaps we shouldn’t be surprised to find non-executives continuing to rise to the challenge and taking on these roles.