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  • GoodGovernanceInstitute

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

    www.good-governance.org.uk

    october 2015

  • Good Governance Institute

    GoodGovernanceInstitute

    1

  • GoodGovernanceInstitute

    GoodGovernanceInstitute

    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

    info@good-governance.org.uk

    www.good-governance.org.uk

    2

  • Good Governance Institute

    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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  • GoodGovernanceInstitute

    4

    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 its 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

  • Good Governance Institute

    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,

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