Where do we go now with governance?  Wales is bedding down new structures and arrangements and England is about to embark on a journey into the largely uncharted waters of GP Commissioning Consortia.  There is a general perception that governance structures have become unwieldy and unfit for purpose: ‘The Board had no idea’.. what was happening on the ward at night.  (Airedale Hospital Inquiry into patient deaths, 2010).

Governance needs a rethink to combine the strategic vision for the organisation with the ability to demonstrate ownership and a grip on patient care.  Our colleagues’ research at OUBS has shown that NEDs can really have an influence on resources but have been less good at quality.  Our work with the Health Quality Improvement Partnership (HQIP) suggests Boards have yet to use their clinical audit capacity strategically to provide assurance of compliance with clinical standards and patient safety.

We cannot move forward with the current trajectory of ever more central directives, board meetings, a plethora of sub-committees, controls, assurance and regulatory investigations. There is too much reworking and too little action to improve, to do the right thing.  In South Africa the King III Corporate Governance Framework applies to all public and private institutions and has moved beyond the more common ‘comply or explain’ UK model to embrace ‘apply or explain’.  A board may conclude that applying a recommended practice is not necessarily in the best interests of the enterprise and apply a different practice provided that it explains the practice adopted and its reasons for doing so.  I would go a step further and use ‘apply and explain’.  The Board should disclose which principles or practices they have decided to apply and explain why these, and not others.  This explicit level of ownership would streamline systems but also allow stakeholders to comment on and challenge the board to improve levels of governance.

This may have resonance in Wales but would seem to be a suitable model for GP commissioners.

Written by Dr John Bullivant, WIHSC Visiting Senior Fellow in Governance