Gravedad API

Although central common themes recur in the historical development of public service delivery in Wales, successive programmes for government and sustainable development strategies have progressed separately. Apparently conflicting

objectives remain. The interplay between politics, economics and the moral claims for social justice is apparent from the drive for efficiency savings as a means of sustaining publicly owned services and creating jobs for economic development, fairness and economic wellbeing, but the overall approach has been that of making sustainable development a social, rather than specifically environmental or

economic policy matter. Changes throughout the temporal development of successive strategies and programmes have built upon experiences gained, but have nevertheless been slow, fragmented and have concentrated on the easy targets and measurement, rather than the difficult qualitative, enduring and deeply embedded social policy issues.

The Sustainable Development Bill, in the Assembly’s current legislative programme, suggests a shift to a more directive approach. Whilst it may, in principle, strengthen the current position and become a key tool for leadership, in practice its

effectiveness will be highly dependent upon the ability to identify the responsible

126 party against whom to take action, the sanctions that can realistically and

proportionately be imposed, and the resources and mechanisms for enforcement.

Sustainable development is overtly framed as a process within this Welsh

governance framework, and as such the danger with tighter regulation is that it will promote compliance with process, leaving sustainable development a rhetorical device rather than stimulating innovation and behavioural change. Accountability through public reporting also remains weak without a tried and tested means of measuring action as well as outcomes. Embedding sustainable development in everyday practice therefore remains a cultural, rather than just a political, challenge.

Whilst sustainable development is intended to be the primary organising principle of the Welsh public sector, delivering services is guided by the principles of value for money. WG retain their leadership role within this best value agenda by guiding and steering by example. Despite research and expert advice that the structures for public service delivery need to be aligned with processes, the constitutional

structures of WG largely remain divided by department and function, governance thereby relying on cross-cutting thematic strategies within the political frameworks, underpinned by core values, to guide, rather than regulate for change. The

fragmented approach is further demonstrated by the way in which procurement has been framed as the external spending power of public bodies, with an emphasis on the outcomes of that spending in terms of local sourcing, rather than any holistic view that challenges both need and needs within the purchasing organisation.

The transition to a more strategic view of the role of procurement, as part of service planning and design, is, however, demonstrated by its situation within the Strategic Planning, Finance and Performance Division, led by a joint head of finance and procurement. Nevertheless, the continuing emphasis on aggregation,

standardisation, simplification and partnership working, in practice, suggests perceptions remain within the narrow functional conception of procurement as purchasing.

The political emphasis is on partnerships¹⁰ as a structure for service delivery can avoid procurement regulations where delivered entirely within the public sector, although the underlying principles of fairness and transparency remain. The

particular benefits of partnership structures are, however, the constitutional link with Government. Rather than devolve responsibility and accountability to corporate

10 In this context partnerships are considered to be both in respect of hierarchy, as between government and devolved organisations, and as networked structures between public and/or private organisations.

127 entities, partnerships enable a more reflexive and adaptable structure where

responsibility and accountability can be assigned to individual roles, arguably a more robust and accountable approach than legislation. Whilst the use of

partnership structures does not necessarily retain service delivery within the public sector it does achieve the political aim of keeping public services in public

ownership. Thus constitutional structures, opposed to regulation, are potentially critical instruments of governing. Partnerships, opposed to sub-contracting or absolute devolution, also enable shared values and assumptions, such as equity, to guide behaviour towards cultural change.

The way in which public services are structured demonstrates the state’s

commitment to citizens, rather than markets. Retaining effective and efficient public services can reduce systemic waste, whether by the elimination of duplication, as in co-ordination and co-operation, or as the retention of economic activity within the region, perhaps as a form of economic resilience or of sustaining public services.

Where the delivery of public services is devolved to subordinate bodies,

Government can lead by example, but can also provide supporting structures to steer behaviour towards desired outcomes.

The supporting role of Government for procurement practice, at the interface of the market, is undertaken by VW, the connection to the wider political agenda apparent from their involvement with organisational development, the promotion of

procurement policy and strategically by their engagement with European partners in procurement reform. Policy promotes the use of the SPAF to assess organisational performance on sustainability, and the SRA for individual projects. In both cases, collaboration with external sustainability NGOs in their development legitimises the respective processes in respect of the sustainable development agenda. The policy focus on collaboration and procurement outcomes is also directly related to local economic development and keeping the Welsh £ within Wales.

At the point where public bodies are exposed to markets for goods and services in the procurement of food provisions, the powers of public bodies are not only constrained by market structures, but by conflicting political objectives. Market structures for locally produced food, for instance, constrain to the ability of public bodies to meet local objectives in their purchasing activities, but also demonstrate structural and political conflicts between economy and health. Welsh agricultural production is dominated by the red meat and dairy industries, areas targeted for reduced consumption as part of a healthy diet, and by SMEs and micro-producers.

Hybu Cig Cymru (Meat Promotion Wales), for instance, emphasises the need to

128 export in order to sustain the industry, and thereby prioritises profitability and

competitiveness over localisation, resilience and environmental sustainability (Jones, 2012).

Such conflicts are particularly apparent in the absence of Welsh lamb on the ‘Public Plate’. Demand from outside Wales, for both lamb meat and breeding stock,

supports those who argue for regional and international competitiveness and bringing money into the Welsh economy, whilst the risks attached to market demand suggests that re-localisation can produce a more resilient domestic food system and retain the Welsh £ within Wales. Market structures, in terms of competition from other consumers, were cited as barriers:

“the trouble with Welsh local food is that it’s always pitched at a premium product and it’s never going sell to the masses …. but there must be some way of doing it. We can’t all have the best meat in the world at the high level – it’s unsustainable.”

Both Welsh lamb and beef enjoy PGI status, but beef is generally cheaper in comparison, although enjoys equal nutritional status. There is, therefore, no health claim, economic incentive or rational logic in budgetary constrained public sector for organisations to purchase Welsh lamb when the alternative, beef, is a quality local product, particularly in the case of hospital food, where the costs cannot be

recovered from the patient.

With 67% Welsh lamb and 93% Welsh beef (WG, 2012b, p.25) consumed within the UK, there is also an argument that WG should prioritise capacity development in other sectors, such as fruit and vegetable production, where the story is one of potential rather than achievement. The Welsh fruit and vegetable industry only represents about 2% of the Welsh agricultural economy (WAG, 2010e), and as such cannot meet the range and demand from the public sector, despite calls for public procurement to purchase Welsh produce.

The narrative of change within the context of public service delivery is therefore one of aspiration, adaptation and transition. The aspiration is that public services should be structured around process, rather than hierarchy and bureaucracy, which will structurally link citizens’ individual and collective needs with outcomes, for sustainable development and best value. This external context of public service delivery demonstrates the potential mechanisms of change as integration rather than economic rationalisation; differentiation; leadership, constrained by external

129 markets, and the devolution of powers to Local Authorities and the NHS, and

perhaps double, but not triple, loop learning (Argyris and Schön,1978).

The future challenges for WG are to continue to make progress within diminishing financial resources, strengthening the need to retain the broad economic and social benefits created by public services as a whole, rather than just expenditure at the interface with markets, within the Welsh economy. Where market transactions, as sourcing and contracting, do take place, Government support through the

procurement route planner not only guides best practice, but legitimises planning and specification based upon quality criteria as part of best value.

The relatively good practice in the NHS, acknowledged by McClelland (2012), suggests that structural or constitutional integration might be necessary to achieve best practice across the public sector, the poor example of Local Authority

purchasing perhaps a result of greater financial devolution, including raising revenue direct from council taxpayers, and more localised political behaviour through directly elected representatives.

These issues are explored further in the following Chapter which considers the specific area of healthcare governance as the immediate context within which nutritional care takes place. The DHSSC does, however, provide an example where formerly separate government departments have been integrated, providing

constitutional ties between separate bodies with devolved responsibility for the delivery of health, social care and public health services, further reinforced by joint senior roles with the NHS.

130

CHAPTER 4 Healthcare Governance

4.1 Introduction

Chapter 3 set out the framework within which Welsh public sector bodies, including the NHS, are expected to operate in order to simultaneously attain best value and sustainable value objectives. The NHS is a publicly funded health system, delivery of services within Wales being devolved to WG. LHBs and NHS Trusts have further devolved responsibility and resources to deliver healthcare services and to be accountable to Government and citizens. As the internal context for this study, this Chapter outlines the way in which healthcare services, relating to hospital care, have evolved and how they are planned and structured to achieve aims which have increasingly been structured around principles of public health and care, rather than the treatment of illness.

The early foundations of the wider NHS in England and Wales are, however, contextually significant to the current NHS in Wales. Focusing on the historical development of NHS Wales since Devolution covers the period from when WG was able to direct and steer a pathway towards sustainable development and citizen centred services. The historical narrative is therefore intended to provide the material from which the underlying reasons for change can be drawn as well as the background for a description of the present governance structures within healthcare.

The provision of hospital services is now planned and delivered by the 7 LHBs, supported by NHS Trusts for ‘All Wales’ services, an arrangement that came about through a major restructuring of healthcare provision that integrated the vertical divisions between primary and secondary care, and reduced the number of

organisations providing localised care. These have been supported by ‘All Wales’

clinical and operational bodies, structured as partnerships. The resultant

streamlined structures were intended to improve efficiency, by reducing duplication and waste, but also removed the inter-organisational boundaries perceived as barriers to delivering patient centred care.

These healthcare bodies, despite having devolved authority, responsibility and accountability, are structurally tied to Government, senior roles, and thereby accountability, shared between NHS Wales and WG. Within the healthcare governance framework, the constitution of the LHBs and key roles of Board

members are also centrally defined, whilst sustainable development and best value

131 are instrumentally embedded in the respective constitutions. Healthcare governance is also arranged around a constitutional framework of strategies, standards and values, with evidence of emerging innovation in the use of process based structures as ‘care pathways’.

The principles of sustainable development, framed as equity for social justice, are embedded in healthcare standards with values of dignity and respect promoting equity as well as guiding behaviour. The standards demonstrate leadership from the nursing profession in setting best practice, and emphasise care at the core activity of hospital based activities, but also stress the role of patients, the experiences of whom are incorporated into accountability. The framework of

accountability, internal and external audit, inspection and self-reporting, is designed to capture the quality of patient experience and patient safety and ensure that clinical concerns drive efficiency rather than cost. Accountability is, however, undergoing transition, from periodic sampled inspections to one of continuous performance management, with action, rather than compliance, playing an increasingly important role.

The Chapter begins with an account of the structuring of healthcare governance since Devolution, followed by a description of the political, ethical and accountability frameworks of healthcare governance and concludes with discussion of the

emerging themes within this healthcare context. The Chapter provides the

immediate context for the focus of this study, the governance of nutritional care in hospital settings.