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Governance review Welsh Health Specialised Services CommitteeFinal Report from Good Governance Institute (GGI)

www.good-governance.org.uk

october 2015

Good Governance Institute


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Governance review Welsh Health Specialised Services Committee

Final Report

Client: Welsh Health Specialised Services CommitteeProject name: Welsh Health Specialised Services Committee: Governance Review WelshDocument name: HealthSpecialisedServicesCommittee:GovernanceReviewfinalreportReference: GGI-WHSSCGovReview-Report-01 15-Final.docVersion: Final ReportDate: April 2015, Reviewed October 2015Authors: Andrew Corbett-Nolan, Chief Executive, Good Governance Institute, Hilary Merrett, Senior Associate, Good Governance Institute, Michael Wood, Partner, Good Governance Institute, Hannah Campbell, Research Analyst, Good Governance InstituteReviewed by: Chris Smith, Team Leader for Research and Policy, Good Governance Institute, CalumGaffney,CommunicationsOfficer,GoodGovernanceInstitute

This document has been prepared by GGI Limited. This report was commissioned by the Welsh Health Specialised

Services Committee. The matters raised in this report are limited to those that came to our attention during this

assignment and are not necessarily a comprehensive statement of all the opportunities or weaknesses that may exist,

nor of all the improvements that may be required. GGI Limited has taken every care to ensure that the information

provided in this report is as accurate as possible, based on the information provided and documentation reviewed.

However, no complete guarantee or warranty can be given with regard to the advice and information contained

herein. This work does not provide absolute assurance that material errors, loss or fraud do not exist.

This report is prepared solely for the use by the board of the Welsh Health Specialised Services Committee. Details

may be made available to specified external agencies, including NHS Wales and external auditors, but otherwise the

report should not be quoted or referred to in whole or in part without prior consent. No responsibility to any third party

is accepted as the report has not been prepared and is not intended for any other purpose.

© 2015 GGI Limited

GGI Limited, Old Horsmans, Sedlescombe, near Battle, East Sussex TN33 0RL is the trading entity of the Good Governance Institute

[email protected]


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Contents

Executive summary 4

Background 5

Review method 6

High level findings 7

List of recommendations 8

Operational governance 10

a. Purpose and vision

b. Strategy and planning

c. Leadership

d. Risk and agility

e. Information and assurance

f. Quality and outcomes

g. Probity and reputation

h. Decision-making

i. Board supports and committees

j. Individual patient funding requests

Conclusion 21

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Executive summaryThis report from the Good Governance Institute (GGI) of the governance arrangements for the Welsh Health Specialised Services Committee (WHSSC) was asked to consider:

• decision making processes through WHSSC and Local Health Boards(LHB) governance models and suggest improvements • each element of governance on its own terms and suggest improvement - especially the Joint Committee • how WHSSC could best fit in the Welsh Government three year Intergrated Medium Term Plan(IMTP) planning processes and the Performance Management Framework • how LHBs could exercise their WHSSC responsibilities more effectively as both commissioner and provider

Through a series of interviews, document review, enquiries of stakeholders and examining models from elsewhere we were able to evaluate the governance arrangements of WHSSC against the principles of good governance and best practice in terms of the important elements of the organisation and operation of effective public sector governance.

We found that whilst those involved were doing their best to make the current governance structure work, the paradigm in which WHSSC is governed does not best serve the effective governance of such a significant and sensitive national function such as the commissioning of specialist services for the people of Wales. Particular attention needs focusing on finding the right structure for WHSSC and the relationships between the various stakeholders.

Considering each element of the terms of reference in turn:

Decision making processes through WHSSC and LHB governance models

This would benefit from urgent structural reform. The issue is that WHSSC is not structured in a form that allows swift, decisive policies and actions to be agreed that will ‘stick’, and where this has been achieved it is at superhuman cost, and often undermined by perceptions of conflict of interest by key players. WHSSC needs to be set up with a board that contains it’s own independent members that are not independent members of other health boards and no longer hosted within a Local Health Board. Options from creating a new statutory organisation through to a much more independently operating hosted service need specific evaluation. The calibre of WHSSC as a significant commissioner needs addressing through investment in the staff and the profile of the leadership team being elevated to that of peers of other commissioners in Wales.

Improvements for specific elements of governance

There are too many layers of governance to foster robust decisions being taken at pace. The organisation could benefit from a greater degree of clinical input at senior levels. The perception of an inherent conflict of interest at the Joint Committee hinders decisions being made, and when they are made, sticking. The chief executives of the Local Health Boards are in an impossible position in terms of being both commissioners and sometimes providers of specialised services and this shows. Incremental improvements within the current arrangements have delivered as much as they are likely to do without the whole governance structure being recast. We feel that the genuine and concerted efforts of the recent leaderships of WHSSC to improve the governance have shown as much benefit as there is to be had, and indeed evidence that the current model can never deliver the strategic steering, oversight and independence that is needed for the national commissioning of specialist services on behalf of the people of Wales. The managing director of WHSSC should become an Accountable Officer and be considered as a peer to the other chief executives commissioning services in Wales.

The Welsh Government 3 year IMTP planning processes and the Performance Management Framework


The genuine efforts to raise the profile of specialist services by WHSSC in the IMTP process is to be commended. Greater independence by WHSSC being buttressed by WHSSC being held to account as a commissioner with genuine KPIs of its own is needed.

LHBs could exercise their WHSSC responsibilities more effectively as both commissioner and provider

The Local Health Boards govern specialist commissioning on an ‘out of sight out of mind’ basis, unless and until there is an immediate local ramification. Then they react to promote local interests over national. It is acknowledged that whilst WHSSC is established by Regulations and the confirmation of services are agreed annually, this process should be strengthened. Local Health Boards need to formally delegate specialist commissioning away from themselves and then hold WHSSC properly accountable for the effective commissioning of these at a national scale. Each Local Health Board should make an annual and specific delegation to WHSSC around what WHSSC commissions on its behalf, and WHSSC as a national organisation should operate a true unitary board model as a fit for purpose means of providing the right attention to strategic development and governance oversight for these delegated responsibilities. WHSSC should have fully devolved autonomy buttressed by proper governance sign-off from each Local Health Board.

BackgroundIn 2010 the seven Local Health Boards (LHBs) in Wales established the Welsh Health Specialised Services Committee (WHSSC) to ensure that the population of Wales has fair and equitable access to the full range of specialised services. The Joint Committee is a relatively new arrangement and, for the first time, brings LHBs in Wales together to plan specialised services for the population of Wales. This is a fundamental change in the way these services are planned and has required the creation of new systems and processes to reflect these new arrangements. These have included new corporate and financial reporting arrangements.

GGI was appointed in November 2014 by WHSSC to carry out a review of its governance.

The objectives of this review were to:

• consider decision making processes through WHSSC and LHB governance models and suggest improvements • consider each element of governance on its own terms and suggest improvement - especially the Joint Committee • consider how WHSSC could best fit in the Welsh Government 3 year IMTP planning processes and the Performance Management Framework • consider how LHBs could exercise their WHSSC responsibilities more effectively as both commissioner and provider

Our findings and recommendations fall into two distinct categories because WHSSC is unique. Firstly, there are findings and recommendations that, in essence, are about the good governance of the organisation as it currently exists. Much of this concerns operational governance, and the day-to-day control of WHSSC as it is.

However, we feel that there is a glass ceiling that will soon be reached to any improvements made to just the current structures and systems. We suggest that there are more fundamental and pressing issues that we feel are best addressed. These include how the NHS in Wales views and utilises WHSSC, and how WHSSC is developed over the coming months and years ahead. We recommend that issues such as the reputation and standing of WHSSC, and how it is able to help the NHS in Wales make complex and difficult decisions and then see them through, are the important governance developments that need to take place. On the principle that form should follow function, if the function of WHSSC is to ensure that the best decisions are made around commissioning specialist and tertiary services for the people of Wales, then it will need the governance arrangements appropriate to discharging this function.

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Review methodDuring November, December 2014 and January 2015, the following work was undertaken:

• interviews with a range of WHSSC and senior personnel and other key internal and external stakeholders from LHBs • review of relevant documentation • observation of Joint Committee and Management Group meetings • production of a draft report of initial findings and recommendations

Following review of the issues within the report with the leadership of WHSSC and at the Joint Committee, this final report has been prepared.

The first section of this report gives a brief commentary on key findings for each element of governance, addressing the issues highlighted in the Background section above, plus a section on the additional element of the Individual Patient Funding Request process. It also gives high-level recommendations against these findings where applicable. Our recommendations are based on evidence gathered during the activities listed above and are only formulated in response to a need identified from one or more source.

We then go on to discuss the issues around how to make WHSSC a ‘best in class’ commissioner, accountable for commissioning the care of patients with significant needs and spending over £600 million of public money in doing so. This touches on issues such as reputation, LHB governance, behaviours and performance, and creating a more independent WHSSC as an equal party commissioner as a peer of the LHBs.

Limitations

The review team is aware that many initiatives are underway at WHSSC to address some of the issues raised in this report. We have endeavoured to take these into account but it is possible that we remain unsighted on some improvements already achieved.

Acknowledgements

The reviewers would like to thank everyone who has participated, including interviewees and those providing documentation and organising meetings.


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High-level findingsWHSSC is not a legal entity in its own right. It is a virtual collaboration of the Health Boards in Wales set up to discharge a discrete set of responsibilities around specialist commissioning. The Welsh Government set up WHSSC as a statutory Joint Committee of the seven LHBs. This is intended to locate specialist commissioning very much within the day-to-day work of the Health Boards rather than as a function of central government.

However, and as in the other countries of the UK, the effective commissioning of specialist services is not just about developing skills and systems to administer this function. The development of specialist services that match population needs, service developments and create high quality patient care involves strategic insight, complex and difficult decisions and effective influence over the development of services and markets both within Wales and beyond.

All those we interviewed recognised both the complexity and scale of the task WHSSC has before it, and that significant improvements had been made under the leadership of both the previous and current Managing Directors and previous Chairs. Governance was signalled out in particular as an area where improvements had been made. The conduct of meetings, the quality of information and papers and the approach to decision making have all clearly been improved since the summer of 2014. However, this is not enough to deliver commissioning of specialist services at the pace and to the degree of independence that is required to best serve the people of Wales.

Much of our findings and recommendations address the nuts and bolts of good governance practice as described, for example, by the HQIP GGI Good Governance Handbook and the various other governance codes that the NHS works to in the various parts of the UK. We feel that attention to these operational governance issues will continue to bring benefits. However, the major task to address is more in the realm of how the Health Boards view and use WHSSC, and the influence that WHSSC is able to develop. The behaviours of the Health Boards towards WHSSC and decisions WHSSC make will be the measure of how effectively the governance is working.

For this reason WHSSC needs to commence work on a programme to develop and agree a national strategy for specialist services in Wales, and a framework for how WHSSC operates and takes decisions. These will provide the Health Boards with both a direction of travel, and an agreed approach to decision making. With an agreed strategy and framework it will be easier for WHSSC to make evidence-based but sometimes brave commissioning decisions that will serve healthcare in Wales well.

The Health Boards will also need to individually make formal decisions around reservation and delegation to ensure that any strategy and framework allow WHSSC to operate within a properly governed and accountable system, rather than relying on the authority of the individual chief executives working together as a collective. We acknowledge that a formal collective delegation to WHSSC was made in the past, but each LHB as it is currently constituted should make an individual delegation to WHSSC to avoid later conflicts when individual decisions may seem to be against or for the interests of individual LHBs. This needs to be refreshed with a specific delegation by each LHB each year.

Reputation is a tool that enables authority. The reputation of WHSSC is, at best, mixed. Significant attention is needed to understand how WHSSC is viewed by its ‘client’ Health Boards and others in the NHS in Wales and England. The reputation of WHSSC as a whole requires serious attention to help develop the credibility and authority that an effective commissioner needs. WHSSC needs to be seen as a trusted and professional provider of commissioning services within Wales, and an authority whose decisions are respected. Achieving this will in part be connected to extending the improvements of the current managing director to how the service is operated, but will also involve some structural changes to WHSSC and a change in behaviours. Key to this will be WHSSC becoming a genuine national organisation with its own Accountable Officer reporting to an independent Chair, although this could remain structured within a hosting arrangement but in a suitable national rather than local organisation.

Within the current governance paradigm, there are various improvements underway and we recommend further ones.


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List of recommendationsGGI has compiled a number of recommendations, which are listed below:

1. We recommend that clarification around the purpose and vision for WHSSC, and reminding stakeholders of this, should be an element of the recently initiated strategy development work.

2. An operating framework should be developed to guide the day-to-day work and decision taking of WHSSC. This should be underpinned by an agreement by the LHB around ethical issues relevant to specialist services.

3. We recommend that the Managing Director of WHSSC is recognised as an Accountable Officer, and is accountable solely to the Chair of WHSSC. The recommendation that the current arrangement of making the Managing Director of WHSSC an executive director reporting to a Health Board is inappropriate. The arrangements for WHSSC’s status should be reviewed. At the least and in the short term the hosting of WHSSC should be moved to a national organisation.

4. The independent Chair needs to be part of the Wales Chairs’ Group that meets with the Minister, in the same way as the Chair of the Emergency Ambulance Services Committee(EASC) does’.

5. There should be an explicit role statement for all types of Joint Committee members and deputies, incorporating guidance on potential conflict of interests where members may have provider and commissioner interests.

6. The performance management framework should be revised to include actions or sanctions to be taken on non-compliance with Joint Committee(JC) decisions and on failures in contract performance.

7. Commissioning metrics for the performance management of WHSSC should be developed to evaluate the effectiveness of WHSSC, and these should be monitored centrally.

8. Current plans to adjust WHSSC governance structures should consider the need to:

• make all directorates accountable for actions in line with WHSSC principles and goals for clinically- driven commissioning • strengthen clinical leadership at JC level and across specialties / networks. This will require a change in Welsh Government Regulations • develop a clinical engagement plan that makes explicit the links between providers and specialty networks; and with Royal Colleges and other advisory bodies

9. Prioritise the recruitment of a full time Director of Nursing. Implement a development programme that addresses:

• the Executive Director role • Executive team working • JC membership roles

10. Review and strengthen the role description for supplementary Independent Members, and consider the appointment of Independent Members who are solely members of the WHSSC JC.

11. Review the requirements and rewards for IMs and AMs. The various groups with IM or AM representations should be reviewed to establish whether they are adding value and link back to assurances WHSSC needs. All groups would benefit from being given a refreshed remit or being brought to a close.

12. The OD plans should include means of benchmarking and learning from peers and peer organisations. We recommend that this includes commissioners in England and especially with Commissioning Support Units.


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13. The next stage of the Corporate Assurance Framework should include specification of the roles of each WHSSC group in the assurance system and illustrate this graphically. This should then be communicated and tested within WHSSC.

14. Standardise approaches within LHBs on the escalation of WHSSC risk issues to their Boards.

15. Prioritise actions to embed risk management across WHSSC and include progress as a standing agenda item for the designated assurance committee.

16. The information strategy should be aligned to the new Quality Framework and supported by training and development for key staff.

17. A uniform minimum data set required from all providers should be devised, building on that described in the Quality Framework.

18. The principles identified in the proposed Quality Framework should be used as a basis for commissioning criteria.

19. A baseline service specification framework should be agreed.

20. A directorate responsible for quality should be identified, with the Director of Nursing post being its executive lead. Sufficient resource should be provided to support data analysis and quality improvement.

21. The implementation of the Quality Framework, incorporating issues as highlighted in this report and in this section in particular, should be prioritised.

22. A Quality Impact Assessment process for cost improvements, including that within the Quality Framework, should be adopted and implemented as a matter of urgency.

23. The most effective pathways for management and sharing learning from all feedback should be identified and adopted.

24. Review the business cycle in the context of adjustments of the assurance process.

25. Means of engaging stakeholders in decision-making should be clarified and monitored to ensure they are effective.

26. The specific role of the Integrated Governance Committee(LGC) within the assurance structure should be revised in the context of other committees.

27. The attendance of LHB representatives at all meetings should be monitored against requirements and contribution incorporated into evaluation.

28. Evaluate the adequacy of information governance assurance.

29. Specify the seniority and roles of LHB members of the Management Group and devise sanction for non-compliance with attendance.

30. Evaluation of committee effectiveness, of committee proceedings and supports should be implemented as per Standing Orders.


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Findings in detailThe findings of our review are measured against the key elements of good governance. Our recommendations are summarised in italics within the text for each element.

A. PurPosE And vision

Purpose and vision are important, because an organisation cannot be governed, and held to account by stakeholders, if the purpose of that organisation is unclear.

The overt purpose of WHSSC is clear and well-understood, but we found that many interviewees feel that in practice, the fact that the chief executives of the LHBs are both provider and commissioner can be difficult at Joint Committee (JC) level. It was felt by many that Cardiff and Vale (C and V) and Abertawe Bro Morgannwg (ABM) are significant providers of specialised services and seem to be mainly defending their position (examples regarding cardiac and plastics - decisions may not be in the best interests of patients e.g. where long Referral to Treatment waiting times (RTTs)). However, this is reportedly improving.

There was a very strong view that the WHSSC has historically been finance driven and not quality driven and a big culture shift is required to change this.

It was felt that there was a north-south divide, with WHSSC’s focus being very clearly on South Wales, with less attention to North Wales and where services are commissioned from England.

We recommend that clarification around the purpose and vision for WHSSC, and reminding stakeholders of this, should be an element of the recently initiated strategy development work.

b. strAtEGy And PLAnninG

An organisation without a strategy cannot be held to account, as the way in which it intends to fulfil its purpose has not been developed and set. It is the minimum duty of a leadership to ensure that a strategy is in place, and that risks to achieving this strategy are understood and mitigations and controls put in place. Those governing an organisation should have as their de minimis responsibility the assurance that these controls have been set up and are effective.

For WHSSC, we see this is a critical area that needs sustained attention. We feel that, in practice, a point will very quickly be reached where no further governance improvements are possible until a strategy for specialised services is agreed by the Health Boards. We were told that this has in part been started with work on a refresh of strategic objectives. It appeared to us that the need for a strategy was all the more pressing as the Welsh Government intend to introduce new priorities in-year. Without a strategy there is no defence against this.

WHSSC is working hard to fit into the planning rhythm of the Health Boards, and has been very much involved in the on-going development of the three year plans of the Health Boards. Some real benefits are starting to accrue from this with consideration of specialist commissioning becoming part of the planning fabric across Wales.

Strategy and planning improvements need to be linked to how the organisation is able to operate. For this to make the much needed stepped change an operating framework for decision-making, underpinned by an agreed set of ethical principles, should be developed to corral the behaviours of the Health Boards into a united approach.

We recognise this is hard to achieve, especially given the funding pressures within the NHS in Wales, but without the Health Boards agreeing a fair, logical and ethical approach to taking difficult decisions then progress will be inhibited.

An operating framework should be developed to guide the day-to-day work and decision-taking of WHSSC. This should be underpinned by an agreement by the LHB around ethical issues relevant to specialist services.


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Given that WHSSC is not a legal entity in the sense that it is a collaborative hosted by one Health Board, all Health Boards need to make specific board decisions around delegation and reservation so that the Board and executive of WHSSC hold formal delegated powers to see through difficult decisions.

Currently, this power is informally vested in the chief executives and allows the impression that powerful voices dominate, and decisions can become unpicked when they are inconvenient. We understand that this is in spite of a clear governance framework of the Joint Committee. In the long run, we feel that this will be a more comfortable position for the chief executives who have duties, as the accountable officer of their individual LHB, that create a conflict of interest when they need to act as both WHSSC commissioners and service providers. We feel that WHSSC having the delegated authority over specialist commissioning of each LHB and the specialist services budget will in the long-term be in the better interests of the people of Wales.

Each LHB should make a formal delegation to WHSSC of the function of commissioning its specialist and tertiary services. This should include the formal delegation of the budget to WHSSC.

c. LEAdErshiP

There have been significant efforts to strengthen and stabilise the leadership of WHSSC. This is entering a new phase at the time of writing with the appointment of a new Chair and Managing Director. It is important to acknowledge the achievements of both the previous post-holders and all interviewees have reported significant improvements and renewed confidence at WHSSC, attributable to these individuals.

The leadership role of WHSSC should incorporate scrutiny of governance arrangements and decision-making, performance management and ensuring the contestability of decisions. The Chair and Managing Director need to be empowered to ensure that the way in which WHSSC works day-to-day and the way in which the Joint Committee operates foster good governance practice and ensure that fair, robust decisions are made in the best interest of the people of Wales.

The Chair is a ministerial appointment, and is independent of any single LHB. We commend this structure. The Managing Director has dual reporting lines, both to the Chair and also, ‘in managerial terms’, to the chief executive of the host. The pay for the Managing Director is pegged at Director level for the LHB. The Managing Director is not an accountable officer. We find this an uncomfortable arrangement, and not fit for purpose for an organisation spending in excess of £600 million of public money. Nor does it give specialised services commissioning the standing or clout it needs to facilitate complex and difficult decisions that have impact of all LHBs - doubly so those that are also providers.

We make a separate point about the ideal type of organisation to host WHSSC later in the paper, but recommend that the status and reporting lines of the Managing Director are promptly addressed. It is important for the effective leadership of specialist services commissioning in Wales that the post of Managing Director always attracts a senior and high-calibre individual and is seen as being on a peer level with Accountable Officers of other significant NHS bodies in Wales. There will be a trickle-down effect to the other members of the director team within WHSSC, which again will help WHSSC be seen as an important public service body in Wales discharging an important and significant role.

The logic of the current arrangement makes the chief executive of the host organisation accountable to the Chair of WHSSC.

We recommend that the Managing Director of WHSSC is recognised as an Accountable Officer, and is accountable solely to the Chair of WHSSC. The recommendation that the current arrangement of making the Managing Director of WHSSC an executive director reporting to a Health Board is inappropriate. The arrangements for WHSSC’s status should be reviewed. At the least and in the short term the hosting of WHSSC should be moved to a national organisation.

The independent Chair needs to be part of the Wales Chairs’ Group that meets with the Minister, in the same way as the Chair of the EASC does.

The Governance Accountability Framework sets out accountability and process for the committee and its sub-committees clearly. However, there is no clear statement of the role of LHB members (i.e. the Chief Executive Officers) and we suggest that this is strengthened. While it can be argued that their role is to follow and fulfil the terms of reference of the committee, as indeed it is, there is a need to address the issue of


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whether they represent the populations of their LHBs or the wider population of Wales. Our understanding is that, for WHSSC purposes, it is the latter, but previous experience and behaviour have occasionally indicated otherwise. This affects the reputation of WHSSC as a body capable of making robust decisions on behalf of patients.

There should be an explicit role statement for all types of Joint Committee members and deputies, incorporating guidance on potential conflict of interests where members may have provider and commissioner interests.

In terms of performance management, there is no clear sanction on providers (whether WHSSC members or not) on failure to comply with decisions or timescales. In the context of a need to drive forward decommissioning and service prioritisation, this gap significantly weakens the influence and standing of the Committee. This is a national policy issue and not just an issue for WHSSC.

The performance management framework should be revised to include actions or sanctions to be taken on non-compliance with JC decisions and on failures in contract performance.

Commissioning metrics for the performance management of WHSSC should be developed to evaluate the effectiveness of WHSSC, and these should be monitored centrally.

There is an acknowledgment within WHSSC that quality should drive decision-making rather than financial consideration. The financial and planning directorates have done their best to be aligned with this intention, but WHSSC needs to become a genuinely clinically focussed organisation with clinicians having greater representation on the executive team. This view is supported by the findings of the Internal Audit report into Standards for Healthcare in Wales that was critical for the planning directorate’s governance self-assessment process. We note this review was in 2013/14 and progress on re-alignment has taken place since.

There are concerns about the capacity of the Medical Directorate to provide and support the right (i.e. strategic) level of clinical leadership. Currently a significant amount of time is taken up with supporting through clinical assessment and evidence appraisal the IPFR process. This is a critical function of the WHSSC and essentially a specialised clinical advisory and administrative role. There are proposals to strengthen clinical governance at senior level within WHSSC by the appointment of a Nurse Director and additional posts within the Medical Directorate, and through the development of a Clinical Policy Group. This is essential to ensure that there is a clear high level steer on clinical policy, beyond the remit of the individual specialty networks.

The roles of Clinical Leads and of Clinical Specialty Gatekeepers need to be clarified in the context of these developments and communicated more widely across the health community.

Current plans to adjust WHSSC governance structures should consider the need to:

• make all directorates accountable for actions in line with WHSSC principles and goals for clinically- driven commissioning • strengthen clinical leadership at JC level and across specialties / networks. This will require a change in Welsh Government Regulations • develop a clinical engagement plan that makes explicit the links between providers and specialty networks; and with Royal Colleges and other advisory bodies

During the course of the interviews and when observing the executive perform at meetings, the review team did not gain the impression that the Executive Directors operate as a team providing a clear leadership role within WHSSC. This may be due to the developing nature of WHSSC’s role and also to the fact that recruiting to the permanent Director of Nursing role has proved a challenge. The new Chair and Managing Director are alive to this issue.

The Interim Director of Nursing, a six month post to develop the WHSSC Strategic Quality Framework, works only two days a week and is fully committed on pressing development issues but finds herself drawn into a range of other operational and on-going challenges. When this role is filled substantively, the leadership role/s for clinical governance can be reframed and reinforced.

There is a need to raise the profile of the Director role within and outside WHSSC, in line with the high level challenges of driving and implementing effective commissioning across Wales.


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Prioritise the recruitment of a full time Director of Nursing.

Implement a development programme that addresses:

• the Executive Director role • Executive team working • JC membership roles

Currently, it is the Health Boards’ responsibility to report commissioning activity themselves. WHSSC would benefit from a means of being performance managed itself in regard to commissioning activities and should be held to account for a set of agreed and defined KPIs.

Independent Members are currently nominated by LHB Chairs. While the current IMs understand their roles and provide a balance of skills and experience, the level of challenge at JC meetings could and should be raised. Some views were expressed to the review team that there should be an IM for each LHB. This, to our mind, would compound the misconception that members “represent” their organisation. However, what would be beneficial would be more IMs, challenging in the context of a clear steer on WHSSC objectives, decision-making criteria and the Committee’s appetite for risk. We see merit in WHSSC being able to recruit their own IMs who are not IMs of other LHBs. This would require a change in the Regulations.

Review and strengthen the role description for supplementary Independent Members, and consider the appointment of Independent Members who are solely members of the WHSSC JC.

There were some concerns about the attendance record of some Committee Members, although we received mixed messages about this. Clarity about expectations of members and about consequences of decisions made at WHSSC might incentivise attendance of members where the role and contribution is currently unclear or undervalued. The level of remuneration and time allocation may contribute to a difficulty in recruiting AMs and should be reviewed. The role of IMs and AMs in the WHSSC Assurance Framework is not yet clearly articulated.

Review the requirements and rewards for IM s and AMs. The various groups with IM or AM representations should be reviewed to establish whether they are adding value and link back to assurances WHSSC needs. All groups would benefit from being given a refreshed remit or brought to a close.

There is an Organisational Development work stream underway. Mechanisms for sharing best practice, twinning or buddying with other commissioning bodies and Directors should be incorporated into the consequent development plan.

The OD plans should include means of benchmarking and learning from peers and peer organisations. We recommend that this include commissioners in England and especially with Commissioning Support Units.

d. risk And AGiLity

The WHSSC Strategic Risk Assurance Framework (or Board Assurance Framework (BAF)), sets out the key risks to current strategic objectives clearly and with scope to detail controls and assurances and appetite for each specific risk issue. Its effectiveness will depend on how it is debated and used to inform decision-making at the Joint Committee. Once the strategic objectives are revised, WHSSC should have a discussion at their Committee meetings about their appetite for risk against each of these.

Risk appetite should be set by the JC for each of the revised strategic objectives. The Strategic Risk Assurance Framework should be refreshed to make it a more user friendly document.

The Executive Board holds the scrutiny role for the BAF and it is “subject to continuous review by the Executive Director lead, Executive Board, Management Group, Joint Committee and sub committees”. The specific roles of each committee or Board in reviewing, moderating, discussing and assuring the BAF should be clarified, especially in respect to the roles of the Corporate Risk Committee and Audit Committee (hosted by Cwm Taf) and the Integrated Governance Committee and the Executive team.


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The next stage of the Corporate Assurance Framework should include specification of roles of each WHSSC group in the assurance system and illustrate this graphically. This should then be communicated and tested within WHSSC.

There is a lack of clarity about how risks identified within LHBs, which may have an impact on WHSSC and vice versa, are shared and addressed through the risk systems. For example, LHBs were reportedly unsighted on the problems in cardiac surgery until the risk materialised. Cwm Taf, as host body, has an advantage in that their Corporate Risk Committee also reviews the WHSSC risk register but there is reportedly confusion about how to identify and address the difference between how risks will affect providers and commissioners. There is scope to standardise approaches within LHBs on the escalation of WHSSC risk issues to their Boards. The review of risk registers at the Cwm Taf committee appears to be fairly high level and would not provide the level of detailed discussion required to assure the JC that risks to quality and safety, for example, are being appropriately managed. The Quality and Patient Safety Committee review the quality and safety risks at a high level and this process should be strengthened to ensure appropriate assurance to the Joint Committee. This may be more appropriate for the Quality and Patient Safety Committee and / or the Integrated Governance Committee. We understand that each risk is currently considered by the relevant Assuring Committee - e.g. Quality and Patient Safety(QPS). The Corporate Risk Committee received the top risks to assure them in terms of the host arrangements.

Standardise approaches within LHBs on the escalation of WHSSC risk issues to their Boards.

The risk management and escalation process is clearly articulated and in line with best practice in risk management. The risk register discipline appears to be well understood across directorates and risk registers reviewed were consistent and there is evidence that they are used locally and are dynamic documents. There is reportedly limited capacity to read across directorates and between organisations to fully understand the implications of risk, however, some doubt was expressed as to whether there is a reality check between risk registers and the key agenda items discussed at Committee, Directorate and network meetings.

Prioritise actions to embed risk management across WHSSC and include progress as a standing agenda item for the designated assurance committee.

E. informAtion And AssurAncE

Whilst not a legal entity, it is useful to the NHS in Wales that WHSSC is seen to be holding itself to account, and should run a governance system that demonstrates this to interested parties. The review team found that there is still work to do to achieve this. The strategic assurance framework process is not yet mature enough to provide robust assurance through effective controls and assurances on all relevant issues. As mentioned above, the roles of WHSSC assurance committees in reviewing the framework needs to be more closely defined and this process graphically described in the developing Corporate Assurance Framework.

The Corporate Assurance Framework also needs to set out:

• process for agreeing risk appetite • how WHSSC assures members and stakeholders that commissioning policy and strategy is driven by strategic objectives • how WHSSC assures itself that operational decisions on delivery are underpinned by clear commissioning criteria • how information is used to provide assurance e.g. risk, performance and quality information • how the assurance system is reflected in the annual business cycle

There are guiding principles set out in the Governance Accountability Framework (GAF) under “Business Framework” which refer to the contribution to the annual business cycle of Chief Executive Peer Group, Executive Directors Peer Groups, Programme Teams and existing governance structures. It is also understood that the interim Director of Nursing is setting up meetings with her peers across Wales. The CAF should make the nature of these contributions explicit.

The role of the WHSSC Integrated Governance Committee is set out in the GAF but was confusing to the review team, as it is it not the same as the arrangement illustrated by the organogram in the Annual Governance Statement. The relationship with the Quality and Patient Safety Committee(QPSC) and the host’s Audit Committee, which are the two assurance arms of WHSSC activity, should be explicit (see the section on Board committees and supports).


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It is evident that the quality of information available to WHSSC to support commissioning has improved over recent months although there is still work to do. In order to inform JC deliberations on the prioritisation of service development, disinvestment and (particularly) improvement, there is a need for better and timely information on:

• service need • best practice in quality and safety targets and standards • benchmarks of quality service • compliance with standards • contract service level agreement baselines (and reported variances)

The ability of non-clinicians to access and analyse information available was also raised.

The information strategy should be aligned to the new Quality Framework and supported by training and development for key staff.

A significant issue in terms of information is the quality of data available from providers. This reportedly varies and there are gaps e.g. the failure of providers in both England and Wales to notify WHSSC of Serious Incidents within two days and to provide complaints information. WHSSC needs to respond rapidly to service deterioration or failing targets (e.g. liver surgery performance) and demonstrate this through its investigation and reporting / learning process.

There are now audit meetings taking place for many of the main specialised services which are seeking to base their business around key outcome indicators. These groups are reporting to the Quality and Patient Safety Committee. This process is understood to be embryonic as yet.

A uniform minimum data set required from all providers should be devised, building on that described in the Quality Framework.

f. QuALity And outcomEs

WHSSC has recognised that it cannot assure Committee members of the quality of commissioned services in the absence of an agreed quality framework. Significant progress had been made towards the development of this framework, aimed at gaining “assurance from all providers”. The proposals seen by the review team are comprehensive and commendably focussed on improvement; in particular the “proposed principles” (slide 25 of November 25th 2014 presentation to Joint Committee) set out a helpful framework for the development of decision-making criteria for commissioning, as highlighted elsewhere in this report.

The principles identified in the proposed Quality Framework should be used as a basis for commissioning criteria.

There is a statement within the GAF that all Health Care Agreements should set out the standards of service quality expected, but it appears that these are tailored to each agreement and there are no standardised or basic criteria e.g. accreditation / NICE guideline compliance etc. We would want these to extend further than the standard quality requirements set out currently in the Heads of Agreement that would help address this. In terms of contract development and management, there is a need to develop a structured approach to how providers will fulfil contracts.

Quality issues e.g. basic requirements for quality services, including, for example - turnover, equipment, premises, - are inadequately specified in some cases. Consequently, there is no clear route for remedial action or sanction when the quality of provision falls short.

Quality data is increasingly being used to populate the performance dashboards, but we feel there is work, building on the Quality Framework, to ensure that there is a minimum data set communicated, consistently collected, analysed, reported on and debated.

A baseline service specification framework should be agreed.


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There are particular concerns around cardiology and Child and Adolescent Mental Health services (CAMHS) and on high cost/low volume services, such as IPFR treatments. These concerns are not only on performance against quality and safety indicators but, importantly, on the ability to evaluate outcomes and thus inform JC decision-making on the value of services and the effectiveness of decision-making.

The interim Director of Nursing is working with the Medical Directorate, the Patient Care team and the Corporate team to support clinical governance, including quality and safety activity. There is no single designated quality or directorate driving clinical governance and quality.

A directorate responsible for quality should be identified, with the Director of Nursing post being its executive lead. Sufficient resource should be provided to support data analysis and quality improvement.

The Quality and Patient Safety Committee is the assurance arm of the WHSSC and a paper has recently been developed on quality approach and inspection process.

While developments are underway and there is a good understanding of what needs to be done, the risks to achieving the goals of the proposed quality framework are not inconsiderable and it is not clear that they are universally understood or well managed.

These include:

• resilience risk as progress depends on co-operation between departments and individuals rather than a well-designed process • over-commitment of the part-time interim Director of Nursing (DNS) • risk that Finance and Planning directorates or programmes do not understand the quality agenda and their essential contribution to and responsibility for it • over and above her contracted time commitment resilience • duplication of the new quality process with LHB activity • under resourcing of new quality process • failure to test the process in a manageable way

In terms of compliance with Standards for Healthcare Services in Wales, there is a very detailed action plan in response to the Internal Audit report on processes, which highlights Safety in Clinical Care as a vulnerable area. The plan is to address all areas within one year and WHSSC needs to be able to demonstrate how it monitors progress to this challenging ambition.

The implementation of the Quality Framework, incorporating issues as highlighted in this report and in this section in particular, should be prioritised.

There is a defined process for identifying cost improvements and prioritising these, but reportedly no quality impact assessment process to ensure that the quality and safety of services is not adversely affected by change. This is an urgent requirement for the committee.

A Quality Impact Assessment process for cost improvements, including that within the Quality Framework, should be adopted and implemented as a matter of urgency.

The Patient Care team reports on learning through current quality reporting, but this needs to be structured and underpinned by metrics as described previously in this report. The new quality framework will formalise demonstration of learning from WHSSC activity.

The resourcing of this activity is also an issue: each LHB has a Putting Things Right budget which should cover learning from concerns about specialised services delivered to LHB patients. The management and ownership of complaints appears to present some problems where services have been commissioned through WHSSC.

The most effective pathways for management and sharing learning from all feedback should be identified and adopted.


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G. Probity And rEPutAtion

For WHSSC to have authority it must have a strong reputation that copper-bottoms some of the complex and difficult decisions that WHSSC needs to take, and see through. This is a theme we found returned to again and again in the interviews.

It is important to understand that it is reputation, though not probity, that is an area of concern. There are worries around conflict of interest, and while interests are declared and carefully recorded the perception of many is that little is done to work through difficult issues.

There are mechanisms to address any perceived conflict of interest issues with the host, but the reputational standing and strength of WHSSC seems to be effected by it being lodged in a LHB. We feel there is an argument for WHSSC being hosted by a national body in Wales. This would require a change in legislation. There were also perceptions, which we felt unfair but potent, that the independent members of the Board had a first loyalty to their Health Board. As we have previously stated, we feel there are arguments for appointing independent members to the WHSSC board who were not members of any other board in Wales, along the lines of the incoming Chair. Again, this would require a change in legislation.

Quite bluntly, we were told again and again that WHSSC’s services weren’t especially good, and that the calibre of many of the staff was not high either. We are not in a position to judge whether this is or is not the case, but it is relevant to the effective governance of the organisation as this perception effects the ability of WHSSC to carry authority and to see through difficult or unpopular decisions. We were given the impression, through our interviews, that the staff group have ‘been forgotten’, with little focused training and development attention and no investment that does not match their important national role.

h. dEcision-mAkinG

Most interviewees emphasised the strong contribution of the previous interim Chair and previous Managing Director in supporting good decision-making in a difficult environment of potential conflicted interest. While there is a dispute process that has been used, WHSSC relies to some extent on specific individuals and their ability to manage personality and conflict, rather than on a resilient process to support decision-making. Again, this is linked to reputation.

This report has previously highlighted concerns about the need for clear criteria for commissioning decisions, a minimum requirement for Service Level Agreements (SLA) with all providers and better information to inform challenge and decision making. The Managing Director is currently working on making the SLA framework more robust.

Some confusion was also expressed around how the funding formula and risk sharing agreement are developed.

There is a concern that decisions are not always transparent and that there is a divide between clinical and non-clinical committee personnel (i.e. between the Medical Directorate and other finance / planning directorates) in this context.

As highlighted above, the approach to potential conflict of interest between provider and commissioner interests is unclear and undoubtedly affects the ability to demonstrate a robust approach to decision-making.

Some concerns about the speed and efficiency of decision-making were noted. There appears to be a tendency to request more information and further papers to be brought to the Joint Committee, rather than debating the issues at committee. The business cycle may thus need to be tightened up to ensure that the timing of decisions is clear and can be met. This may also reflect a lack of confidence by some members in issues that are relatively new e.g. disinvestment.

Review the business cycle in the context of adjustments of the assurance process.

The quality of committee papers observed was very good with a high degree of clarity about the purpose of papers and what type of action was required by the receiving committee or group. The Joint Committee meeting observed was characterised by a tight grip on ensuring that decisions were recorded and views obtained. However, these are the views of those seated around the table, and there is scope to improve


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confidence that other stakeholders, both internally and externally, have been appropriately consulted and have been able to contribute appropriately to agenda items. This would improve the ability of the JC to be more proactive in making decisions. It is also true of feedback of stakeholders, especially LHBs, after meetings.

The Business Framework (within the Governance Accountability Framework) refers to peer groups to support decision-making - e.g. CEO and ED peer groups and Programme teams. It is not clear how this input is gained and used.

Means of engaging stakeholders in decision-making should be clarified and monitored to ensure they are effective.

i. boArd suPPorts And committEEs

Almost by definition, the WHSSC committee structure is more complex than other health service structures. This is mainly because of its relationship with Cwm Taf LHB, as its host body. This presents some challenges about clarity of assurance, particularly in view of the potential overlap between the Audit Committee, the Integrated Governance Committee and the Quality and Patient Safety Committee (QPSC). Previous sections on Information and Assurance and on Decision-making are relevant for general recommendations, but we cannot condone the current audit committee structure as being a sufficient means for audit committee oversight over an organisation as complex or as important as WHSSC. The issue of perceived conflict of interest was raised too, there being concern that ‘WHSSC’s banker’ was auditing itself.

The functions of the Audit Committee, Corporate Risk Committee and Information Governance Committees are provided for WHSSC by Cwm Taf committees. The Audit Committee was not observed but is understood to cover review of the WHSSC risk register, and its progress against action plans. It is attended by a WHSSC Independent Members and reporting into other WHSSC committees appears to fulfil statutory functions. The CT Internal Audit Charter does not specifically mention its role with joint committees. The CT IA Charter was to be amended to reflect WHSSC.

The Integrated Governance Committee seems to duplicate the Joint Committee to some extent as it receives papers from sub committees including chair and director reports. However, its members should have a better grip on WHSSC issues than all members of the Cwm Taf Audit Committee may have and it should have more agenda space than the Joint Committee has. As the QPSC has just revised its terms of reference, it may be time to review the IGC as well and consider what its role is and whether it is still required. If it is truly to be the overall governance committee with oversight of all sub committees (as per original terms of reference), it may need to meet more frequently and the business cycle will need to be reviewed.

The specific role of the IGC within the assurance structure should be revised in the context of other committees.

The QPSC has a considerable agenda which strays beyond its assurance function. This indicates a need for a group with a good understanding of the clinical aspects of commissioning: the proposed Clinical Policy Advisory Group may be able to fulfil this function in future, allowing the QPSC to focus on assurance, reinforced by better data following on from the implementation of the quality framework. This may also help with time pressures on meetings, which currently postpone important items due to lack of time. There are also issues around attendance of LHB representatives at the QPSC. However, the minutes and other evidence collected seem to indicate that LHBs may not attribute sufficient importance to this committee and to quality assurance generally for specialised services.

The attendance of LHB representatives at all meetings should be monitored against requirements and contribution incorporated into evaluation.

It is important to be confident that WHSSC information governance issues are adequately covered in Cwm Taf Information Governance Group meetings: this appears doubtful from documentation reviewed but may be misleading. In view of the importance of IG issues for specialised services (e.g. the IPFR process), the JC must be able to assure itself that these issues are adequately managed.

Evaluate the adequacy of information governance assurance.


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An additional feature unique to WHSSC is the role of LHBs in relation to WHSSC. There is much good practice in LHBs on reporting but the review did not scrutinise all LHB processes and there is a need to standardise and communicate the roles and responsibilities of provider Boards and committees with regard to specialised services commissioning and provision.

The Executive Board meets monthly but, while referred to in governance documentation, did not feature during the review as a key influence on delivery of strategy. The Executive Board is reportedly not resourced sufficiently, nor does it appear to be regarded as a cohesive team. The responsibility for driving through strategy is delegated to the Management Group (see below).

The Management Group is the body responsible for the implementation of the Specialised Services Strategy, on behalf of the Joint Committee. It has a mix of commissioners and providers as members but the overwhelming impression gained during the review was that the balance is not right at present and that this group does not fulfil its remit. Taking this in the context of the comments above about the Executive Board, this is a serious challenge to governance for WHSSC. A key problem is the level of seniority of attendees. Apart from Cardiff and Vale, most LHB representatives and attendees are finance or planning officers. While the meeting observed was well run and constructive, there are concerns in the following areas:

• issues discussed tend to be operational or administrative • items may get deferred or rerouted back up to the Joint Committee (inappropriately) • it was felt by some that feedback on Management Group discussions does not always get back to CEOs and thus to LHBs, even though a report on the Management Group is included in the Directors Report to each meeting along with the minutes • discussions may be overly finance-oriented • meetings tend to be extremely long • the nature of meetings is more of an exchange of information than taking action on delivery of WHSSC strategy

Specify the seniority and roles of LHB members of the Management Group and devise sanction for non-compliance with attendance.

There is also a lack of clarity about the roles of networks and advisory groups, which is borne out by both interviews and review of documentation. The Welsh Renal Clinical Network is the only sub-committee of WHSSC (i.e. it holds a budget and is responsible for commissioning and monitoring services): the others are advisory bodies. This is not universally well understood. At the time of writing the CEO of Cardiff and Vale UHB is reviewing the networks. From this review we would make the following recommendations:

• the role/s and concomitant accountability for group chairs need to be clarified and revised in the WHSSC Governance Accountability Framework • liaison with other peer groups - e.g. Medical Directors, Nurse Directors - should be formalised for both Wales and England • a forum for professional advisory group chairs may be helpful

In terms of committee administration, the agendas observed were well constructed and clear. Where summaries and headlines are used, these have been welcomed by committee members and should be used across the board. LHBs in Wales use the SBAR (Situation, Background, Assessment, Recommendation) discipline for papers and reports. It was not clear during the review as to whether the prescribed annual evaluation of committees has been undertaken and what the results may be. This is a priority for the governance system.

There were conflicting views on meeting support and the quality of minutes and papers: it was clear however, that there is an enormous burden of paperwork and significant time pressures on the corporate team to satisfy the business cycle: some of the recommendations in this report are designed to ease this burden where possible.

Minutes are generally good although one issue from the Welsh Renal Network meeting was noted whereby verbatim notes of adverse comments about another organisation might pose problems where transparency is concerned. While action log discipline is good in terms of capturing actions and responsibilities, some actions within minutes express intentions rather than describing how actions will be achieved e.g. “there will be improved discipline ...”. Timescales and monitoring mechanisms also need to be recorded.

Evaluation of committee effectiveness, of committee proceedings and supports should be implemented as per Standing Orders.


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J. individuAL PAtiEnt fundinG rEQuEsts - obsErvAtions on thE ProcEss

The Patient Care team manages the IPFR process and is responding systematically to the recent Internal Audit (IA) report on the process, which gave Limited Assurance on the totality of the process as opposed to the IPFR element. Of between 1500 and 2000 requests per year, many are routine (e.g. holiday dialysis) but about 80 will be referred to the All Wales IPFR Panel. The All Wales IPFR procedure is followed with representation from each LHB on the panel and access to ethical advice. The Panel is currently trying to recruit a lay member.

There is a weekly Support Group, which decides which requests need to be referred to the Panel, which meets monthly. This timing causes some issues where urgent requests are concerned, or where the non-urgent become urgent due to slow processing. There is an escalation process to deal with urgent issues outside meetings and the default position is always to treat in a medical emergency.

There is now a meeting with all LHBs to review issues of concern which has simplified communication considerably.

The following are our key observations on the process:

• there is a need for decision-making criteria where a treatment is requested and there is no agreement in place. This is reportedly under development• the IPFR team has to liaise with both the medical team and the planning team: each of these approach decisions from a completely different perspective: this can delay decisions• the clinical expertise and experience of the Patient Care Manager is invaluable to the successful operation of the request procedure, but this is not formalised into the process, making resilience an issue for the whole process• the Clinical Gatekeepers role is not well understood by incumbents. They can give authority to agree funding on behalf of WHSSC and approve the first OP appointment if there is a SLA with provider. There are occasions where their approvals extend beyond the first appointment and additional expense is incurred, which can be significant. This is not routinely monitored or addressed• it is currently difficult to identify the cost of IPFRs as many are embedded in SLAs• we understand that the Panel approves almost everything defined as urgent• there are cases where the delays have created urgency where it did not originally exist and thus additional or unnecessary expenditure may be incurred• delegated financial limits have been overridden by email and the Patient Care Manager is not technically authorised to approve all funding requests that she has: while this issue has been recognised and Standing Orders reportedly will be amended accordingly, the fundamental issue appears to be the responsiveness of the process through the panel / support group meetings• the IPFR form is very complicated and was criticised in the IA report• relationships and liaison arrangements with providers vary considerably• poor attendance at the support group and also non-attendance by Powys LHB at the Panel were raised in the IA report. It is not clear how much influence or pressure WHSSC can or had brought to bear to rectify this• the IPFR treatments / providers database is not currently fit for purpose and is difficult to access: while the team is competent and effective in accessing information on treatments and providers, this is also an issue of system resilience• the lack of information on the effectiveness of treatments was picked up by the IA report and is part of a wider issue for WHSSC in terms of evaluation of service provision• there is a lack of confidence that IPFR issues and their implications are incorporated into the Strategic Assurance Framework as a risk to WHSSC strategic objectives. This was reported in the Audit Report


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ConclusionGGI thanks WHSSC for the opportunity to review the governance of the organisation. Our review took place at a transitional time. A new Chair and Managing Director were appointed during the course of our review. At the same time, various improvements initiated by the former Chair and Managing Director have been continued. We also observed a Hawthorne effect from our review.

Within the current paradigm for the organisation and leadership of WHSSC the governance arrangements are fit for purpose, though need significant updating. However, while they do the job, the current paradigm should be changed. They are not the best model for the commissioning of specialist services at the scale Wales requires. The governance step-change that WHSSC requires is to arrive at a place where governance form follows organisational function. As demands on healthcare budgets increase year on year, WHSSC needs to make strong and sometimes unpopular (to some) decisions in the best interests of the people of Wales. It needs the organisational freedom and authority to do this, and there are elements of the current governance arrangements that do not allow this. Some can be achieved more simply than others. For example, the formal delegation by each individual LHB of the function of and budget for specialised and tertiary commissioning on an annual basis would be possible within the current arrangements. This would help to minimise difficulties in decision-making and potential for conflicts of interest, but would not in our view be enough. It is evident that the standing and independence of WHSSC needs attention. Government decisions would be needed to recognise the Managing Director as an Accountable Officer, create specific IMs for WHSSC and place WHSSC within a national body within the NHS in Wales. We would suggest Public Health Wales as the obvious candidate.

We feel these changes are not cosmetic, but would create a profound change in the ability of WHSSC to fulfil its mission and purpose. Not doing so leaves the present situation, where there is a clear conflict of interest around the Joint Committee table, unresolved. The current structure can look elegant on paper, but in terms of a working model where the best decisions can be taken for the people of Wales the status quo is not the optimum model. The structure as it is now disables the Joint Committee from being able to desegregate their interests as a commissioner from the practical problems of running a provider organisation with its own local interests, accountability for resources and individual organisational strategic aspiration. Our recommendations will free the system from what we feel are very real constraints to making the best collective decisions. Conflict of interest is a very real ‘elephant in the room’ for the Joint Committee and the opportunity presented by our review to name this should not be missed.

Alongside this, the already started strategy for specialist and tertiary services in Wales is a key step and WHSSC should be empowered to lead this. For day-to-day, an operating framework based on agreed ethical principles and sensible organisational operations should be developed to guide decision-taking. This should include attention to behaviours by all stakeholders.

WHSSC has a key role in the NHS in Wales. Looking over the border to England and further, specialist commissioning is only set to become more complex, interesting and challenging. The time is right to make sure that the way in which WHSSC is governed is appropriate for such an important and developing function within the NHS in Wales.


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