Improving strategic governance — the role of the developmental standards in the Standards for Better Health

Introduction

Since 1997, the Labour Government has been developing a vision for reforming the National Health Service (NHS). The new view of health care is based upon an assumption that all NHS organizations, which includes hospitals, primary care trusts (PCTs), and ambulance trusts will work together to provide improved patient care in a way that promotes patient choice. The message is – collaborating while competing (13 December 2005 speech by the Right Honourable Patricia Hewitt MP, Secretary of State for Health at the London School of Economics, to the Annual Health and Social lecture). The ambition of the reform programme is to deliver radical change to ‘the whole system’ – changing the relationship between the providers of care and the public and patients to what is now termed a ‘patient-led’ NHS. ¹

The changes are in line with a wider Governmental reform programme for the whole public sector, which is based on a number of principles: ²

Balancing local flexibility in service design with equity in service quality is the single biggest challenge faced in implementing the reforms. The NHS is intended to be an equitable and nationally integrated health-care service. However, the reform agenda in emphasizing local accountability and responsiveness is creating pressures that operate against consistency. Innovation in services cannot be controlled nationally and service design cannot be standardized. ‘Greater delegation of responsibility will mean a greater risk of inconsistency. The public is rightly intolerant of this, with complaints of ‘postcode lotteries’ in health care. There will need to be a counterbalancing increase in local accountability to allow local decisions to be scrutinized and justified.’ ³ All these require much greater joint working and partnership between PCTs, local authorities, NHS foundation trusts, NHS trusts, the independent sector and voluntary organizations. The solution is the creation of a set of national standards, to which every organization will work, which ensure universal quality while permitting local flexible approaches to innovation in service delivery, thus allowing ‘scope for local determination of what works best’.^4,5 The Department of Health's standards, entitled ‘the Standards for Better Health’ were designed to focus the NHS on ‘the quality patients receive’ with an exhortation to ‘concentrate on delivering an NHS that is more qualitative and focused on what the public and patients want from a 21st century health system’ (John Reid: foreword to National Standards Local Action, 2004). The standards are a series of high-level statements, which provide a generic standardized focus for all organizations on key aspects of quality (including governance, clinical and public health aspects and patient experience) and which ‘sit at the heart of the new relationship between central Government and the NHS, under which it is the role of the Department of Health to set broad, overarching standards defining the Government's high-level expectations of the health service’.

The Structure of the Standards

The standards are divided between seven domains, which identify the broad parameters for the management of health care. They provide a template for the key areas that the boards of NHS organizations need to ensure are addressed when making decisions about service planning and delivery (Figure 1).

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Figure 1

Seven domains of the standards for better health

The Standards for Better Health contain two distinct sets of standards: core and developmental. The core standards are intended to bring together and rationalize key existing requirements for basic features of any health service, and address the minimum level of service patients and service users have a right to expect, e.g. the appropriate control of health-care acquired infection. ⁴ The core standards merely outline the basic requirements for good health care, which all NHS organizations need to address in their operational management.

The role of the developmental standards is different from that of the core standards (Box 1). The domain statements and the developmental standards together provide a strategic quality framework within which service innovation can take place. On the basis of the Government's vision for modern health care, ‘The NHS Improvement Plan’, the developmental standards are intended to move the NHS ‘into the next phase of reform of the health service’, which is intended to deliver 21st century health care. In this way, the developmental standards aim to encourage the boards of NHS organizations to abandon ‘old ways of doing things’ and to think in different ways by overcoming traditional ‘institutional barriers’. The standards provide the impetus for organizations to ‘challenge the past, use innovation and creativity to determine new local solutions, and set new horizons for local services’ (Sir Nigel Crisp: Preface). ⁴

The developmental standards therefore are intended to ‘signal the direction of travel’ as laid out in the vision for the future of health care and to specify the key strategic areas that organizations need to consider, if they are to deliver integrated and patient-focused services. They cover 13 distinct but inter-related areas, which describe the key quality parameters associated with a well-functioning health-care system (Box 1). The developmental standards are based on some clear assumptions about partnership working and the key infrastructure needed to support the new vision of health care in line with increasing patient expectations. They therefore emphasize key issues in partnership working, placing patient needs at the forefront of service design and delivery and the need for coordinated patient care, which spans organizational boundaries. The Secretary of State announced, in December 2005, the intention to ‘view the National Health Service not just as hospital buildings, but as a network of services, helping us to stay healthy as well as treating us when we are ill’. The developmental standards emphasize this view of the NHS as a network of services. Their aim is to remove discontinuities in patient care, which may occur when organizations fail to join up around the patient, through the development of new approaches to governance and management, which encompass inter-organizational working, and to include for example the development of integrated risk management systems, combined governance systems and comprehensive information technology systems based upon ‘whole systems thinking’ for health services. The intention of the developmental standards is that they should be seen as a coherent whole, linking an individual organization to the other organizations with which it shares the provision of 21st century patient care (Figure 2).

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Figure 2

Role of the developmental standards in board strategy

Using the Developmental Standards

Boards of organizations providing health care within the NHS have to recognize that they are part of a wider health-care system and will be held accountable to act collaboratively in the interest of patients. This requires a new approach to the governance of healthcare organizations and new methods for demonstrating accountability. Boards are therefore encouraged to use the domain statements and the developmental standards to structure their strategic planning processes to ensure consistency in the quality of service design and delivery.

Ideally, boards will integrate the domains and the developmental standards into their strategic thinking and their governance processes for two reasons: first, so that the board actively pursues the development of the whole system of health care and do not pursue organizational success to the detriment of individual patient care; and second, so that the board has a universally accepted framework, which can be used to demonstrate accountability – in that their collective deliberations demonstrate that boards place adequate emphasis on serving the wider needs of patients. The domains and the developmental standards should play an important part in the assurance and accountability approaches used by boards in order to show that they are actively committed to an integrated system-wide approach to the provision of health care.

The Health Care Standards Unit is working with NHS organizations to identify ways in which the developmental standards and the domain statements can be incorporated into their governance processes and frameworks through the development, for example, of improved approaches to construct Assurance Frameworks, improved board challenge to executive decision-making and improved strategy writing (For further information, see www.hcsu.org.uk).