NHS Governance

SHA policy

This is a discussion document not agreed policy.

All NHS bodies must be under clear obligations and duties:

  • To work to reduce inequality
  • To cooperate with other public bodies
  • To promote shared decision making and community development
  • To be open and transparent and to involve public and patients in all major decisions and plans.
  • Mergers and other organisational changes should be subject only to local agreement.
  • NHS bodies should have boards of directors with a majority of NEDs and governing bodies set up to reflect a balance between patients, public, staff and other local stakeholders.
  • The procurement and contract management of major assets should be the responsibility of the Secretary of State with NHS Bodies subject to an appropriate reasonable internal charge for use.
  • We require national standards, national service frameworks, national outcomes frameworks and inspection and regulation on a national basis; and national terms and conditions to allow staff to move easily within the NHS. We already have national systems for collection of data and an obligation on all providers to supply that information.

Accountability and Transparency

  • The SHA supports patient choice and greater involvement by patients in their own treatment. This is not choice as a market mechanism and there may be some limits in the interest of overall efficiency predicated on patients / citizens / public responsibility.
  • Co-production is the process of working with NHS users. This applies at a macro level, planning local and national NHS services in collaboration with citizens and users; it also applies at an individual level in the consultation between patient and clinician where shared decision-making takes place. Care must be delivered with as much participation in shared decision-making as the patient wishes at the time.
  • The NHS must commit, therefore, to both listening AND RESPONDING to citizens and using adequate mechanisms for this.
  • We therefore commit to responding not only to needs as defined by clinicians, but needs as defined by users and citizens. We see the process as a meeting of experts – the NHS offers its clinical expertise. The patient is an expert on their own strengths – and the impact of ill-health on them. The community can, with help, identify key issues that matter to them and work with the statutory sector to address those issues – evidence shows that this process protects health.
  • Ensure an independent and adequately funded Healthwatch and comparable bodies in Wales, Scotland and NI.
  • Community development and community development workers will be supported and funded to increase communities’ input into planning and to increase the responsiveness of NHS organisations.
  • Such a systematic approach at individual and collective levels will require the development of processes such as:
    • Decision Aids
    • Full Record Access to primary, secondary and social care
    • Group appointments
    • Rapid feedback of users’ views to health and care organisations
    • Community development
    • Patient and community views of responsiveness and experience of services should become routine outcome measures for NHS performance
    • NHS organisations must demonstrate the changes in planning that they have made in response to individual and community recommendations
  • There will be appropriate training and workforce delivery to ensure effective individual and community participation
  • There will be an NHS-wide volunteering policy with appropriate support and payment.
  • Values important to patients like dignity and respect should be demonstrated in every service provided.  This should be informed by widely available and meaningful information about the performance of and outcomes from health care services, local and national.


The current NHS has three “domains” that have to work together. These are the political domain, the professional domain and the managerial domain. Some writers on management in the public services claim that these three domains are necessarily in a state of conflict with – at any one time – two domains aligned against the third. The political process decides which two challenge the third and on what.

The political domain mediates, through the political process, what the NHS is to deliver (and what is isn’t). It is expected to exercise political oversight of how it performs – both at the national levels (England Scotland and Wales) and at the local level through the Board / Trust machinery acting on behalf of the Minister (or the head of the NHS in England). The political domain is largely driven by a 4-5 year cycle linked to the electoral calendars in the three countries. Devolution has complicated the frequency of elections and hence shortened the time horizons available to politicians in devolved systems. Politicians justify their legitimacy by reference to their mandate. Their aim is usually to deliver what they believe they can persuade enough of the electorate ( sometimes their share of the electorate) to accept. This means they operate to a political rationality.

The professional domain – doctors nurses etc – claim their legitimacy from “their” patients, whose interests they seek to represent. The professional domain can be divided between the different professions and often within professions (e.g. GPs v Consultants, surgeons v physicians). Their time horizon is much longer as often they seek engagement over decades if they are pursuing a career. Their rationality is based on science and experience – that is, they claim to know what “works” – and this is a different approach to that of the politician. The professions guard their professional rights closely in maintaining standards of, and controlling entry to, the profession.

The managerial domain seeks to find a unifying set of aims around which their discrete organisation can gather – using such techniques of short and medium term plans, change management and quality improvement, etc. Often the managerial domain will relate to the public by simply seeking to keep services running in the hope that it will deliver the best it can for the most it can. It’s rationality is the wider public service.

(You will note that the three domains each see “the public” in different ways and there is little agreement as to how the three domains different views of “the public” may be reconciled. Indeed, part of the analysis underpinning domain theory assumes that each domain will seek to get “the public” on its side – e.g as in the junior doctors dispute). How “the public” itself fits into the domains isn’t clear.

Managing the NHS and the wider care system – politically, managerially, and professionally – has been recognised as the most demanding of tasks. The NHS does not conform to the usual management approaches that apply in “normal” businesses – in part because its ownership and the values that drive it are unlike any other, and in part because demand seems infinite and resources are limited. Our political processes have found it difficult to match investment in the NHS with what that process can make available. Evidence of “what works” is frequently contested and good practice is still not regularly and readily imbedded across the organisation.

SHA believes that the political domain has to set out more clearly what it expects the NHS to deliver in terms of volumes and range of services. Moreover, it must make explicit what the service is not able to do. The political choices – once made – have to be defended through the political process, and the expected service levels have to be matched by human and financial resources agreed by the wider service as necessary to deliver the services promised. The political domain must not set targets unilaterally or offer resource levels that are incompatible with wished for outputs / outcomes

Professional domains must update professional standards as new services and care methods become available. They must increase their efforts – jointly – to spread best practice and support professionals who need further training or other help. SHA believes that the professions should play a full part in overseeing the delivery of care, ensuring (again jointly) that poor practice is recognised and steps taken on professional levels to rectify matters. Each profession has a duty to advise managers, politicians and the public on the resources needed to deliver safe services – especially for new and emerging therapies. Such advice should be soundly based and will be open to challenge by competent others.

The managerial domain in the NHS should operate to the highest Nolan standards. It should be placed on a professional basis, with a code of conduct that offers protection to its members should they be instructed to manage the service in an unsafe way. It should have a duty of co-operation placed upon it insofar as working with other managers operating in the public sector is concerned. Recognised management posts, such as Chief Executives, Directors of Nursing, and equivalent posts, should have a legal duty to report to Boards (in public) any concerns that they have about service demands and resources. Such reports should be privileged – i.e. their content shall not give rise to legal action by either their employee or any private party mentioned in such a report. The managerial profession should renew the competence of staff in senior grades on a four-yearly basis.