The architecture of NHS governance: Issues and tensions
Two decades of government reforms to the health service in the UK have wrought huge changes to the way these services are organised and governed. At the top-tier level, health governance has been devolved from London to Wales, Scotland and Northern Ireland. Within England, accountabilities for primary, secondary and tertiary care, and mental health services have been redistributed and in a broad sense devolved extensively away from Whitehall outwards and downwards into individual, independent organisations each governed by a board comprising non-executive directors as well as executive directors. There are approximately 5,000 individuals occupying seats on these boards. Achieving ‘foundation trust’ (FT) status frees organisations from control and monitoring by the centre, and from their regional agents, the strategic health authorities (SHAs). In their stead, the trust directors are accountable to ‘boards of governors’ elected by local ‘members’ – patients and citizens of the local communities served by these hospital trusts. The roles and interrelationships between the boards of directors and the governors remain uncertain and unresolved. With the new coalition government in 2010, this process of reform has if anything accelerated with stronger roles for GPs and local authorities. Directors sitting on these trust boards have to negotiate their roles not only with regard to each other but also in relation to the shifting and multiple principles and institutions which form the macrosystem of governance. With the reforms announced in the 2010 White Paper this challenge has reached new heights of complexity. Despite a pre-election pledge to avoid structural change the new Secretary of State went on to trigger one of the most radical upheavals since 1948. One immediate consequence of centre-led intervention was the resignation of the Chair of NHS London along with a number of the other Non-Executive Directors leading to concerns about whether the Board was viable. Examination and clariﬁ cation of roles in the crossﬁ re of these multiple forces is one of the central rationales of this book.