At The King's Fund we work with boards to develop their roles and behaviours and to make them as effective as possible. We spend some time observing them, and thinking about 'what would it be like to sit on this board'. Would it feel open, supportive and honest? Are its members individually effective and do they communicate effectively – for example, do they challenge themselves and others; do they use energetic presentations and have insightful conversations; and do they support their colleagues and have good decision-making skills?
That focus on the behaviours, roles, relationships and competences of the individual, which all affect the dynamics of the board, differs from much of the existing guidance, which focuses on the role and purpose of the board (for instance, The Healthy NHS Board) and on governance processes (for example, Taking it on Trust by the Audit Commission). But in our experience behaviour in the boardroom is key to the effective management of quality. One outcome of the first Francis Inquiry report was a reaction of 'there but for the grace of God go us' by some chairs and non-executive directors (NEDs). Not – we hasten to add – because such extreme failings in care are common across the NHS, but because the more honest and rigorous boards know that there are pockets of their estates, staff and services that are offering care that's poorer than they would like it to be.
So how can boards encourage effective management of quality? First, by learning to listen; boards that don’t listen to patients, governors, commissioners and staff lose the opportunity to put things right. A failure to listen can be prompted by many things, including a fear of challenging one another and of conflict – even the healthy kind – or a lack of trust. How boards handle difficult news is critical, and clinical staff, as well as NEDs and executives, must feel comfortable with bringing bad news to the board when necessary. This is all part of keeping the board honest about its core business, and one reason why working with behaviours is so rewarding. It’s no coincidence that the Nolan Principles, particularly the qualities of openness, integrity and honesty, are at the centre of the values and behaviours required by boards.
Mature boards are able to combine the disciplines of formal board behaviour with the ability to respond in a ‘human’ way to painful scenarios: boards should be able to show an emotional response and not hide behind 'performance management speak'. If they're not capable of a strong response to bad news where will the energy come from to change the situation? Like all teams, boards can be guilty of avoidance on a grand scale.
The competence of individual board members lies at the heart of the performance of whole boards –their ability to deal with difficult issues or to avoid them, to raise the tone of the debate or to reduce it to operational levels, and their skills in getting to the heart of things without ruffling feathers. These are important qualities in board members that may need development or coaching.
The Francis Inquiry may reiterate that quality is the responsibility of the whole board, and if so, many boards will re-visit the subject of the quality of clinical governance sub-committees. The relationship between the sub-committee and the main board is key and, here again, behaviours and culture are important: on an effective board, the chair will think about how to bring the energy and flavour of the sub-committee into the whole board to keep everyone engaged on quality.
And in order to provide leadership on quality – as distinct from leadership on governance – board members, particularly the chair, should make frequent, explicit reference to the values of the board, and members should feel demonstrably closer to the patient. They should be clear about the information they require to assure them that their espoused values are being delivered on the front line and should know where clinical leaders are having an impact on quality. Most importantly, the board should be aware of the kind of organisational cultures that encourage high-quality care.
Making the quality agenda sustainable is a real challenge. In our earlier study, From Ward to Board, we found that quality is a fragile concept at board level. It is relatively easy to keep it at the heart of the agenda when things are going well, but the focus can be easily lost, particularly when financial and performance pressures mount. Sustainability means embedding quality into the culture. If the board is honest with itself and others, has a vision for quality that is linked to a supportive culture in the organisation, and has good information about the business, quality will be harder to ignore.