NHS Tayside Assurance and Advisory Group: staging report of findings and recommendations

7. Governance and Organisation Capacity

In this section of the report we consider the governance structures set up to provide assurance to the Board of NHS Tayside around the delivery of the Transformation Programme, and the resources and capacity available to manage and drive forward the delivery of the actions required to turnaround the Board's current financial position.

7.1 Key Points

• Dedicated governance arrangements have been put in place to oversee the management and delivery of the six workstreams within the Transformation Programme including Executive and Non-Executive representation and supported by a Programme Management Office ( PMO).

• Appropriate staffing is in place to support the PMO function with well-functioning monitoring and reporting arrangements in operation - although these resources are currently time limited.

• Programme documentation is generally well-developed. However, there are areas where further work is needed to improve understanding of interdependencies and the impact of slippage in specific aspects of the Transformation Programme.

• Communications and stakeholder engagement plans across the workstreams were generally found to lack detail. There is a need for enhanced engagement and communication, particularly with clinicians and other front line support staff, in order to maximise the likelihood of successful delivery of the Transformation Programme.

• To date, the role of the Project Management Office has been largely limited to reporting and monitoring progress based on monthly reporting by workstreams. Potential risks relating to the delivery of savings are reported to the higher level governance groups (the Transformation Executive Group and Transformation Board) to resolve.

• Greater emphasis now needs to be given to an enabling and delivery function to reflect the scale and pace of change required and to add capacity to support the operational teams.

• We saw robust governance structures in operation, underpinned by a clear and positive commitment to addressing the challenges facing NHS Tayside. These need further support and development to facilitate strategic and focused decision-making alongside effective scrutiny of performance and delivery priorities.

7.2 Transformation Programme Governance Structures

The Transformation Programme Board was set up in October 2015 as a time-limited Committee of NHS Tayside responsible for the direction and governance of NHS Tayside's Transformation Programme.

The Programme Board is accountable for the success of the Transformation Programme with the Chief Executive responsible for the delivery of the Transformation Programme. The Executive lead for the Programme is the Director of Strategic Change.

7.3 Programme Management Office

The Programme Management Office has the mandate to ensure the effective management of the Transformation Programme. It manages the six workstreams, and reports to the Transformation Executive Group, which is responsible for the delivery and oversight of the Programme. A well-functioning and effective PMO is critical to the success of the Transformation Programme, with the role of providing the management skills and organisational capacity to support the delivery of the required improvements.

A high level review of the structures supporting Tayside's Transformation Programme was carried out by Ernst and Young, assessing them against the structures, governance, process and reporting arrangements associated with leading practice in sustainable improvement programmes. A summary of their assessment is noted below:

	Assessment	Areas for further development
Governance and accountability	Established	Develop and enhance clinical leadership in support of service transformation
Planning	Developing	Embed savings plans at directorate level to develop service ownership Generate pipeline of savings opportunities based on benchmarked productive opportunities
Initiation	Basic	Ensure project initiation documents are in place for all current and future schemes Ensure quality control process and approval is incorporated into all operational delivery plans Develop and embed financial impact within all schemes and plans
Delivery	Developing	Develop decentralised project management support, leading to enhanced support to directorates and service lines
Monitoring and Reporting	Established	Develop rigour of process and monitoring of key performance indicators for the Transformation Programme to provide Tayside Board with the required assurance

The assessment carried out by Ernst and Young indicates that the overall level of resource is in line with that seen in other similar programmes. However, seven of the roles, including half of the full-time staff, have a fixed end date, with assignments coming to an end between May 2017 and December 2018.

Whilst this level of resource is considered adequate, Ernst and Young have indicated that the allocation of resources across the programme do not align proportionally with the scale of savings required. For example, the Workforce and Care Assurance workstream has the largest savings requirement (£8.8m) with two Whole Time Equivalent ( WTE) staff allocated to support it, whereas the Realistic Medicine workstream has a larger resource allocation, 5.8 WTE, for a much smaller saving (£3.4m).

Risks are compiled and assessed by the PMO on a weekly basis, and reported to the NHS Tayside Board via the Transformation Programme Risk Assessment. However, there are indications that appropriate actions are not being put in place with sufficient pace to adequately mitigate the risks of the issues raised. Items initially identified as high risk in May/June 2016 continue to appear on the Transformation Programme Risk Assessment presented in May 2017.

In terms of the range of documentation supporting programme governance, there is mapping of the interdependencies between the multiple strands of work. However no quality and safety impact assessments were provided and there is no comprehensive benefits management framework in place. Benefits tracking is managed by NHS Tayside's Finance team, and currently only tracks financial savings.

Despite the quarterly reviews of workplans, the plans are not consistently of a quality to provide confidence of delivery. There is no clear escalation process to ensure prompt corrective action where anticipated progress is identified to be at risk.

7.4 Engagement across the organisation in transformation programme

Discussions with NHS Tayside Non-Executive Board members indicate they are very aware of the scale of challenge facing NHS Tayside. The Advisory and Assurance Group welcomed the opportunity to attend a number of Board and Executive level groups, site visits and to meet with colleagues from staff partnership, the advisory structure and representatives from the Health and Social Care partnerships.

Key themes that emerged from these discussions included:

• A clear, unhesitating and positive commitment to addressing the challenges facing NHS Tayside.

• Principles of quality and improvement are well established but there was clear recognition that strategy needs to transform existing models of care whilst operating within available resources.

• Meaningful, sustained engagement and effective, mutual partnership working throughout the organisation will be key to achieving the scale of transformation that will be required. Clear and visible leadership from the NHS Tayside Board and its Executive Team around this commitment must be evident at all levels within the organisation. That includes the imperative of optimal realisation of a shared vision of care and wellbeing of the people of Tayside in concert with the three Health and Social Care Partnerships and Local Authorities.

• Recognition that effective leadership will be necessary to set the direction and then support the delivery of change.

• The governance and accountability arrangements across NHS Tayside and its partners need to be developed to reflect the need to evidence and demonstrate whole system commitment to delivery of agreed plans and savings targets.

• A requirement for a step change in the pace of implementation of change and shift and emphasis from planning to delivery.