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The Intended and Unintended Outcomes of New Governance Arrangements Within the NHS

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The Intended and Unintended Outcomes of New Governance Arrangements Within the NHS SDO Project (08/1618/129) The intended and unintended outcomes of new governance arrangements within the NHS Report for the National Institute for Health Research Service Delivery and Organisation programme March 2010 Professor John Storey, The Open University Business School Dr Richard Holti, The Open University Business School Dr Nik Winchester, The Open University Business School Professor Rod Green, Department of Management, The University of Bath Professor Graeme Salaman, The Open University Business School Professor Paul Bate, University College, London ____________________________________ Project Lead: Professor John Storey, Open University Business School Walton Hall, Milton Keynes, MK7 6AA E-mail: [email protected] © Queen’s Printer and Controller of HMSO 2010 1 SDO Project (08/1618/129) Contents Acknowledgements ....................................................5 Executive Summary....................................................6 Background ..............................................................................6 Aims........................................................................................6 About this study ........................................................................7 Key findings..............................................................................7 Conclusions ..............................................................................9 PART 1: POSITIONING THE STUDY...........................11 1 Introduction and background...........................11 1.1 The governance and accountability framework in the NHS .......12 1.2 The shaping of performance by regulators .............................16 1.3 Corporate governance in the NHS ........................................18 1.3.1 The Intelligent Board.................................................19 1.3.2 Integrated governance ..............................................20 1.4 Views of governance from the literature ................................22 1.4.1 Creating public involvement versus state control ...........24 1.4.2 Encouraging competition versus supporting collaboration24 1.4.3 Focussing on “what the board does” versus wider processes ................................................................25 1.4.4 Creating a paper chase versus critically examining performance ............................................................25 1.4.5 Towards autonomy versus more tightly drawn constraints...............................................................26 1.5 Literature on governance and performance............................28 1.6 The focus of our study ........................................................33 1.6.1 Scope and key themes...............................................34 1.7 Summary of key research questions .....................................35 2 Project design and methodology ......................36 2.1 Qualitative research ...........................................................36 2.2 Quantitative research – the national postal surveys ................38 2.3 Research ethics .................................................................39 PART 2: THE FINDINGS OF THE STUDY.....................40 3 Findings at national policy level, SHAs and regulators ................................................................40 3.1.1 National level governance policy makers ......................41 3.1.2 National level regulators ............................................46 3.1.3 Governance of Strategic Health Authorities ...................48 © Queen’s Printer and Controller of HMSO 2010 2 SDO Project (08/1618/129) 3.1.4 Summary ................................................................57 4 Findings about Governance of NHS Primary Care Trusts (PCTs) ...................................................61 4.1 The key issues...................................................................63 4.1.1 The governance status of PCTs ...................................63 4.1.2 Boards as agents of governance..................................67 4.1.3 Clinical engagement in governance..............................79 4.1.4 Governance of partnerships........................................82 4.1.5 Conclusions and wider implications..............................90 4.2 Findings from the Postal Survey of NHS Primary Care Trusts....94 4.2.1 Methodology ............................................................94 4.2.2 Aspects of Governance ..............................................95 4.2.3 Governance and performance ...................................102 4.2.4 Governance and organisational performance using multivariate analysis ...............................................107 4.3 Summary and Conclusions about PCT Governance................ 110 5 Findings about the Governance of NHS Acute Trusts.....................................................................111 5.1 The Key Issues................................................................ 112 5.1.1 Foundation Trust Boards ..........................................116 5.1.2 A Case illustration: Two London Teaching Hospital Trusts ...................................................................132 5.1.3 The Riverside NHS Foundation Trust Renal Unit Case Study....................................................................143 5.1.4 Conclusions from the acute trust case studies .............148 5.2 Findings from the Postal Survey of Acute Trusts ................... 152 5.2.1 Aspects of Governance ............................................153 5.2.2 Governance and performance at the organisational level .....................................................................159 5.2.3 Governance and wider organisational performance indicators using multivariate analysis.........................164 5.3 Summary of findings about governance of acute trusts ......... 173 6 Findings about Governance in Mental Health trusts .....................................................................175 6.1 What is distinctiveness about mental health services? ........... 175 6.2 What are the distinctive governance issues? ........................ 176 6.3 Governance arrangements and board operation ................... 180 6.3.1 Relationships internally and with other organisations ...184 6.4 Summary ....................................................................... 185 PART 3: CONCLUSIONS AND IMPLICATIONS ..........186 7 Sense making about Governance ...................186 7.1 What do national level system designers intend and expect when they make policy choices affecting organisational forms and governance? ............................................................. 186 © Queen’s Printer and Controller of HMSO 2010 3 SDO Project (08/1618/129) 7.2 How do organisational level managers (chief executives and their teams) interpret and respond to the policy message they receive concerning governance and organization?................. 187 7.3 What organisation and governance design principles are used by organisation level directors and managers? ..................... 194 7.4 What perceptions do healthcare staffs have about the new governance arrangements and how are they responding? ...... 197 7.5 Implications for better practice .......................................... 203 7.6 Limitations of the study .................................................... 205 7.7 Implications for research .................................................. 206 References .............................................................208 Appendix 1: ............................................................214 1. Members of the Project Advisory Board ................................. 214 Technical Appendix 1: PCTs....................................215 1. Questionnaire piloting and response rates ............................. 215 2. Questionnaires .................................................................. 216 PCT Questionnaire – Pilot Version.......................................216 PCT Questionnaire – Full Rollout Version .............................223 3. Description of variables in organisational level data. ............... 231 4. Principal Components Analysis – Organisational Level Data...... 233 Technical Appendix 2: Acute Trusts........................236 1. Questionnaire piloting and response rates ............................. 236 2. Questionnaires .................................................................. 237 Acute Trust Questionnaire – Pilot Version ............................237 Acute Trust Questionnaire – Full Rollout Version...................242 3. Description of variables in organisational level data. ............... 247 4. Principal Components Analysis – Organisational Level Data...... 249 5. Exploring governance and performance, analysis restricted to ‘extreme’ trusts. .............................................................. 252 © Queen’s Printer and Controller of HMSO 2010 4 SDO Project (08/1618/129) Acknowledgements The research was funded by NHS Service Delivery and Organisation Programme Research & Development grant SDO/129/2006 (new SDO reference 08/1618/129). We want to acknowledge our debt to the innumerable people within the NHS and beyond who gave generously of their time in answering our many questions. We also want to thank members of the Advisory Board who so readily offered their services and their insights. Finally, we gratefully acknowledge the value of the comments made by three anonymous referees from the SDO who made many useful suggestions in response to their reading of the draft version of this
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