What good assurance looks like for NHS boards

GGI consultant Joe Roberts says effective assurance – based on facts, evidence and standards – is fundamental to good governance

Recognising the importance of good assurance, NHS trusts have been required to have a board assurance framework (BAF) since 2001.

Although for some it may seem like a tick-box compliance exercise – just another paper dappled with red, orange and green boxes to be added to the end of a bulky board agenda pack – the board assurance framework is vital to good governance and a crucial element of the board’s armoury, provided it is designed and used properly.

The role of BAF in effective NHS governance and leadership

A good BAF can help to shape board agendas and cycles of business, making sure the right level of information is reported to the right people at the right times. By bringing together the key risks that prevent the achievement of the strategic objectives set by the board, with the sources of assurance that tell the board whether those risks are being managed effectively, it should prevent nasty surprises.

Yet we still hear about boards being blindsided by regulators uncovering serious issues that the board was unaware of, or did not realise were so serious. The various inquiries into major service failures in the NHS over the years showed us some of the reasons why this may happen, such as unhealthy, defensive cultures that inhibit the frontline clinicians who are most acutely aware of the problems from voicing their concerns, or poorly designed and poorly understood risk management processes that obstruct the escalation of risks upwards through the governance structure. However, another reason may be that the board did not receive the right assurance information – or, if it did, it drew the wrong, usually over-optimistic, conclusions from it.

The structure of a BAF

Typically a board assurance framework will include a column for ‘gaps in assurance’ and these gaps should, in theory, be considered every time the BAF is reviewed by the board or its committees – usually quarterly – with actions put in place to fill them.

In reality, the attention given to this varies considerably between organisations, perhaps understandably so when the BAF is just one item on an agenda that is several hundred pages long, for a meeting that can last half a day or more.

Questions for boards

However, to ensure that meaningful assurance is being given, assessing the quality of the assurances reported to the board is vital. Drawing on our experience of reviewing board assurance frameworks across the NHS, and facilitating their development, GGI has identified six questions for boards to consider. Today we’ll share the first three of these questions:

1. What is the scope of the assurance?

If relying on an audit report or an external consultancy review – we need to be clear about what were its terms of reference, and whether it reviewed the whole of a system or process, or just one or two specific aspects. The auditors or consultants can only provide assurance over what they look at.

2. How objective is the assurance?

This can be difficult to judge, but a starting point is to consider the source of the information. A story from an NHS trust illustrates why this can matter. In a mock inspection ahead of an imminent CQC visit, several staff were observed entering a ward without sanitising their hands. This was inconsistent with the ward’s hand hygiene audit results, which showed almost 100% compliance. At the time, each ward’s hand hygiene audit was done by its own staff; subsequently, this changed to a ‘peer review’ approach where the ward was audited by staff from other areas, and results were significantly less impressive.

Assurance from services themselves – known as first line assurance – has its place, but should never be relied on exclusively. At the very least, the board requires second line assurance, provided by corporate functions that are separate from the service. For example, many NHS trusts have a team within the nursing directorate that undertakes spot checks of wards. Third line assurance is even better. This comes from sources outside the organisation, such as regulators, Royal Colleges, external auditors, and so on.

3. How accurate is the data or information that we are relying on for assurance?

In an ideal world we would be able to take management information as read, but this is not always possible. Some organisations still rely on outdated IT systems that struggle to generate reliable information, and even the best information system is only as good as the data entered into it. For example, depending on how an organisation manages attendance, accurate sickness statistics may rely on line managers recording the absence promptly and accurately on the Electronic Staff Record, something a busy manager may forget to do. Also, we must accept that some information is by its nature based on assumptions and estimates, such as accruals and provisions in a finance report. In such cases, it is more about judging whether those assumptions are reasonable than whether the figures are right or wrong.

We’ll be publishing the second set of crucial questions for boards soon.

Trusted expert help

Need support with board assurance?

As well as being a knowledge institute, we provide trusted specialist leadership and governance consultancy, for which we have a UK-wide reputation. We have supported over 600 boards in different sectors and contexts over the past 12 years, and more than 50 in the last year, to improve their governance, with a significant track record of success. A significant portion of the work we do is board development and board assurance framework related. Our approach to consultancy work is always collaborative and we act as a governance partner to our clients in developing tailored programmes of work.

Find out how we can help you by calling us on 07732 681120 or emailing advice@good-governance.org.uk.