Governance, strategy and innovation in mental health

There is a contemporary move in the National Health Service (NHS) to adopt commercial-style governance for provider trusts. Clinical governance has been developing toward ‘integrated healthcare governance’, and there is now an intense focus on corporate responsibility for healthcare activity, especially in NHS foundation trusts.

Any form of governance requires systems to manage risk and to provide information on performance, which are surely essential tools for all senior healthcare staff. However, governance initiatives may fail if they are overly bureaucratic, and this may be a particular risk in the complex world of mental health. Good governance is therefore of great importance to psychiatry.

Successful governance depends on innovation and integration at a strategic level. This should begin with the culture of the senior staff and directors, and a simple reporting system, such as the balanced scorecard. These must embody a clear vision of future success, based on ‘what really matters’ for patients.

Governance may sound a very dry concept, of limited relevance to psychiatrists. However, in order that large healthcare organisations deliver good services for patients, there must be good governance arrangements of some form. For organisations which are not well run, real innovation in governance is essential for effective clinical practice to develop and flourish. Understanding good governance is therefore crucial to all clinicians, including psychiatrists.

Corporate and clinical governance

Corporate governance is about how commercial companies are run, and the integrity of relationships between company boards, staff, shareholders, customers and society. In practice governance often focuses on the control of company finances, and on board responsibility for corporate risks.

Governance has been developing in the NHS for some years, around finance audit and systems of controls assurance (Emslie, 2004). NHS foundation trusts are now set to have a code of governance (Monitor, 2005) which relates closely to the UK Combined Code on Corporate Governance (Financial Reporting Council, 2003). The Combined Code begins with a clear statement:

‘Every company should be headed by an effective Board, which is collectively responsible for the success of the company’.

In recognition of the potential for improved governance in the NHS, clinical governance was introduced for local NHS trusts, a new concept ‘built on the principles of corporate governance’ (Department of Health, 1997). Scally & Donaldson (1998) gave one of the shorter definitions of clinical governance:

‘A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’.