As Monitor prepares to add mental health access to the risk assessment framework, it is time to admit that the targets are no reflection on foundation trusts’ quality of governance

In the early days of Monitor’s existence, so the story goes, the then health secretary asked the regulator’s then chief executive how it could make foundation trusts comply with national targets, given they would be free by law to ignore them. 

‘“Governance” indicators in the compliance framework originated as national performance targets’

Thus Monitor’s compliance framework was born. 

The story might be apocryphal, but the outcome was that the “governance” indicators in the compliance framework, now the risk assessment framework, originated as national performance targets. 

There is little doubt that, had this route to enforcing national targets not been devised, another approach to risk and governance may have been taken. 

With the benefit of hindsight I think another route would have been better. 

Money talks

Back, in what seems like the distant past, when NHS budgets were increasing by 5 per cent or more in real terms each year, it was argued by Monitor in particular that targets were a reasonable measure of the quality of trust leadership because compliance was an indication that boards could effect change within their organisations where their lesser colleagues might struggle. 

‘Even the weakest foundation trust could probably afford to throw money at problem areas’

When so many factors can affect performance against a target, it was always a tenuous argument that compliance equalled good governance or, more to the point, that non-compliance indicated poor governance. 

But at the time compliance was relatively easy for most FTs to achieve, so why rock the boat? 

Even the weakest could probably afford to throw money at problem areas. And while throwing money at a problem is often not the best solution, it is often a viable solution. 

Most succeeded, very few failed and, where there was failure, it was often accompanied by a clear failure of leadership, which seemed to confirm that the proxies worked. 

Finding the framework

In short there was a consensus in support of the framework – or at least no great impetus to seek to change it.

But the outcome was broad support for a framework that purported to distinguish good governance from poor, but in fact did no such thing.

Much of what was in the compliance framework is now in the risk assessment framework. 

But since the risk assessment framework was devised much has changed. Commissioners are no longer able to meet the full cost of the services they commission and, as income falls, cost improvements and efficiency savings can only take provider organisations so far. 

‘Where there was failure, it was often accompanied by a clear failure of leadership’

It is entirely rational for boards that face falling incomes to try to manage demand, and in so doing some of them will sometimes fail to deliver on access targets. 

Does this make them badly led? It must surely be a better option to manage the situation than try to paint over all the cracks until the roof falls in.

We know that there are well led organisations that are struggling to deliver on targets. It must surely be time to acknowledge that they are not good measures of governance, so it is wrong to base enforcement action on target.

Monitor’s answer to this will surely be that targets are just part of a suite of indicators that it uses to determine whether there needs to be further investigation into a trust. 

True, but it is a bit like saying that the speedometer is just one of a number of ways in which a driver judges the speed at which they are travelling, when we know the speedometer is broken. 

Parity play

So why consider this now? 

Monitor proposes to add to the list of proxies for the first time in years, with the metric of the mental health access targets, ostensibly to reflect parity of esteem. 

But parity of esteem does not mean treating everyone the same. So it is timely to begin a debate on what is the best way forward, rather than looking to further entrench a framework that does not actually measure what it purports to. 

In fact, aside from the difficulties of using national targets as proxies for governance, it feels an opportune moment to review the validity and clinical benefit of some national NHS targets.

Alternative reality

If the risk assessment framework is not doing what it says on the tin, what is the alternative? 

One of the main reasons for using proxies is that the quality of corporate governance is notoriously difficult to measure. 

Typically good boards lead good organisations, but this is not always the case, for a variety of reasons. For example, it takes time for good leadership to bring about a change in organisational culture and until a new culture is embedded, weak organisations will remain weak, even though they might be well led. 

Typically good organisations are led by good boards, but not always – not least because in the short term good management can cover for poor leadership. 

Quality assurance

So where does that leave us in measuring governance?

The Care Quality Commission and Monitor already have a joint framework to assess the degree to which organisations are well led. 

That framework is not perfect and will always be subject to refinement, but it does address the key elements of good governance directly. So it makes sense to move towards using that framework to judge the quality of leadership rather than compliance with arbitrary and sometimes unattainable targets. 

‘We shouldn’t compound past mistakes by adding the mental health access target to the risk assessment framework’

The challenge, though, is how best to utilise the framework in a meaningful way between three yearly reviews without adding to bureaucracy, inspections or the already unsustainable cost of regulation. 

The answer probably lies in a move away from regulation based on compliance to one based on assurance and triangulation, given that assurance is the outcome of the rigorous and effective management of risk. 

Obtaining high quality evidence to provide assurance is one of the key areas of a board’s work.

It should be possible to use the wealth of information already produced by FTs to satisfy Monitor that boards are providing the right leadership. The CQC can triangulate this data through inspection and desk based surveillance. 

This would undoubtedly lead to debate about what we expect from regulation and what it can reasonably be expected to achieve. That debate is needed. 

No pretence

Hopefully the post-election climate will be conducive to an open and honest debate on the purpose and limits of regulation. 

Whether that debate takes place or not, we should at least resolve not to pretend that the existing “proxies for governance” are anything of the sort. 

‘We should not pretend that the existing “proxies for governance” are anything of the sort’

We certainly should not compound our past mistakes by adding the new mental health access target to the risk assessment framework. 

By all means set and enforce clinically appropriate targets in partnership with the sector, but let’s not pretend that they represent a robust means of measuring and evaluating governance.

Monitor’s consultation on the risk assessment framework closed on 18 February. NHS Providers will be discussing the outcome with our colleagues at the regulator. 

We would welcome your feedback. Please contact john.coutts@nhsproviders.org.

John Coutts is governance adviser for NHS Providers

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