OUR NHS OUR CONCERN, DOCTORS ASSOCIATION UK, BAPIO AND DOCTORS FOR THE NHS – WRITTEN EVIDENCE (PSR0032)

Urgent need for a change in culture; Board members should be elected

A case for a change in the Law

The experience of Covid pandemic makes this paper even more relevant

Introduction

‘Beyond the glittering surface of modern technology’ begins an article co-authored by the former chief executive of the NHS in England Lord Crisp (1) ‘the core space of any health care system is occupied by the unique encounter between one set of people who need the services and another who have been entrusted to deliver them. Lord Carter of Coles in his report on productivity in hospitals published six years later commented ‘the workforce is regarded as a cost to be controlled rather than a creative and productive asset to be harnessed’ (2). As Lord Willis of Knaresborough put it in a debate in the House of Lords in 2018: ‘All too often, those who deliver the services, the workforce, are treated as a commodity rather than as a precious resource. The fact that this is the first time in 25 years that the health service in England has consulted on a comprehensive workforce survey is as damning an indictment of past policy as it is ambitious about the future’(3). Despite the above observations there has been no improvement in the attitudes mentioned; indeed, this has got worse.

Low morale continues; people do not feel that they are consulted; they do not feel valued. Bullying and harassment remain unchanged (4, 11). Management remains unaccountable (5). Maybin et al raised doubts about the strength of local accountability mechanisms for both providers and commissioners and concluded that, overall, the NHS reforms signalled a shift to a system that was overly reliant on local mechanisms that were not proven in their efficacy (6). For far too long NHS management has not been held accountable for its failures (7). The entrenched practice of a revolving door allows the current ethos to be maintained (8. 9). Decisions are not made quickly and although the slow process is acknowledged, no effort has been made to make the system efficient, demonstrating the unwillingness of management to change. The culture at the top of management is quickly understood and feared by all.

The failure to retain nurses is serious. The nursing workforce is overstretched, and it struggles to cope with demand. Too little attention has been given to retaining the existing nursing workforce and more nurses are leaving their professional register than joining it (10). This trend is not helped by the current ethos of management. Bullying and harassment continue, and staff are reluctant to report incidents because of a fear that they may be penalised (11).

The way patients are moved from ward to ward in a single admission and the discharge experiences of people indicate the lack of patient centred service. This is also reflected by the current practice of reducing local services thereby causing considerable hardship to patients and their families.

To add to the corrosive ethos stated above, the vast majority of Trusts have consistently failed to meet the targets for A&E, cancer and planned operation although the performance in mental health services was above target (12). Fiscal management has been consistently poor as noted in a report by King’s Fund (13). In 2010/11, just 5% of Trusts providing ambulance, hospital, community and mental health services in England overspent their annual budget. By 2015/16, 66% were in deficit. The NHS provider sector ended 2018/19 with a deficit of £960 million.

Whilst the NHS does need more money, if the NHS is to be sustainable it is even more urgent to alter the current undesirable ethos. Given the current appointment system it is difficult, if not impossible, to believe in the ability of senior management to change the culture any time soon. The most certain way to ensure this change in ethos is to start from the bottom of the service: make every NHS Board subject to regular election.

The proposal is that all members of the board, executives and non-executives, should be elected for a period of three years. The electorate would be for all the people on the pay roll of the relevant Board to be elected. This body would also be able to nominate individuals for any of the posts.

Any individual working in the health service, not necessarily from within the population served, could nominate individuals for any of the posts, and be nominated, given certain qualifications. Each nomination would require at least ten signatories from the relevant electorate. Neither trade unions, political parties nor organisations would be allowed to nominate.

The tenure would be for a period of three years, and there would be no restriction on the number of times an individual can stand for re-election.

Individuals nominated may not represent any political party, trade union body nor any organisation and should not be supported by the same in any way during the election process.

Individuals nominated for the post of Medical Director would be required to be registered with the General Medical Council: a doctor practising within the relevant locality would not be barred from nomination. Likewise, an individual standing for the post of Director of Nursing would be required to be registered with the Nursing and Midwifery Council A person practising in the relevant locality would not be barred from nomination.

Individuals standing for the post of Director of Finance should be qualified accountants, who are members of an accountancy body in the UK, recognised by the International Federation of Accountants (IFAC) and have the relevant experience in financial management of complex organisations. (14)

Individuals nominated for the post of Chief Executive should be able to demonstrate wide experience in senior posts but their fitness for the post would be judged by the electorate.

The number of non-executive posts would be a matter for each area to determine. The Upper Tier Local Authority for the area would select from its Elected Members an agreed number of individuals to serve in non-executive posts, thereby ensuring the voice of the population served by the Board. Such individuals would not be required to seek supporting signatures as indicated above. Other candidates for Non-Executive Directors would be required to be supported by ten signatories. It is perhaps appropriate to mention that individuals with a criminal record or bankruptcy would not be eligible.

The curriculum vitae of each candidate should be distributed to the electorate and be easily visible on the local web site. The time given to each candidate for canvassing must be agreed and defined before an election. This should be discussed and agreed nationally. No canvassing would be allowed on the day of the election. Given the widespread use of social media, this issue requires careful discussion and safeguards put in place.

The election process would be conducted by an independent organisation.

The Board would elect its own Chair who should be one of the elected Non-executive Directors.

The Chair would have direct access to NHS England / NHS Improvement, which would also have the power to intervene when required.

Discussion

The above changes would lead immediately to a change in culture, treating staff as a valued resource. Clinicians would have a stronger voice as to how patients are treated and control over the safety and quality of the care given to their patients. The Non-executive Directors of the Board would be able to exercise their supervisory roles more effectively and be empowered to question the validity of changes proposed by the executive body, leading to increased transparency and accountability. It would certainly raise the morale of the workforce. On almost all functions there will be a change that will lead to a more open culture.

Black Asian and Minority Ethnic people make a large and important contribution to the NHS workforce, but are severely under-represented on the boards of trusts. This has been recognised for a number of years, but the impact of Covid 19 may have made it all the more urgent to address the issue. (19) The proposed electoral measures could play a significant role in ensuring that boards better reflect the entire workforce.

The proposals made in this paper are significantly different from the elected boards piloted in Scotland (15). Only the non-executive members of the boards were subjected to an election and the entire public was expected to vote rather than only those who were employed by the NHS. The public were invited to nominate individuals. Despite the elections being advertised widely the turnout was consistently low and this led to the practice being discontinued. The electorate in this paper will be people who are working for the NHS and are passionate about the NHS. It is inconceivable that such an electorate would not be interested and it would foster a greater interest, understanding and sense of participation in the management of the NHS at a local level.

The board constitution in the UK is based in law arising from the Trust Membership and Procedure Regulations and by Schedule 7 to the NHS Act 2006 for NHS Foundation Trusts (16). A closer look at this law reveals that the concept of electing board members was not rejected; indeed, it was included. In section 9(1) it states ‘More than half of the members of [F6the council] of governors must be elected by members of the corporation other than those who come within paragraph 3(1)(b).E+W’ and in next section it states ‘2)At least three members of [F6the council] must be elected by the staff constituency or, where there are classes within it, at least one member of [F6the council] must be elected by each class and at least three members must be elected altogether’. In another section it states ‘10(1)An elected member of [F6the council] of governors may hold office for a period of three years(2)Such a member is eligible for re-election at the end of that period

Furthermore, Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. They are clinically led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. They are led by an elected governing body made up of general practitioners, other clinicians including a nurse and a secondary care consultant and lay members (17). Given the experience since 2006 and the current state of affairs, it is difficult to understand why the law should not be altered to allow all boards to be elected. The change should not require primary legislation but an amendment to regulations.

Giving more money to the NHS may temporarily alleviate some of the strains but it will not alter the corrosive ethos. The only way to establish a sustainable NHS is to legislate for what is good for patients and the workforce; money alone will not guarantee what all of us want for our precious NHS. It is fitting to conclude this by quoting Baroness Dido Harding, ‘If NHS boards took culture and staff management as seriously as finance, the service would shift from a bullying and rotten culture quite quickly’ (18).