The RQIA: what went wrong

23 Jul 2021 Nick Garbutt    Last updated: 23 Jul 2021

Pic: Unsplash

Last June, during the most severe health crisis we have ever faced, the board of the Northern Ireland’s health and social care regulator, the RQIA resigned en masse.

The letters of resignation expressed concern at what they described as a lack of effort made by the Department to consult or engage with the Board prior to making key decisions affecting the core purpose and statutory remit of the RQIA and dismay at finding about decisions and directions after the event. 

Within 24 hours Health Minister Robin Swann announced the setting up of a review led by governance expert David Nicholl into what caused all this. His findings were published this week.

It is a must read for anyone with an interest in governance and also gives compelling insight into some of the inner workings of health bodies as they responded at pace to an unfolding crisis.

The report runs to 131 pages but is crisply written and makes for a compelling read. And like all the best investigations into things that go wrong there is a clear focus is on what can be learned from the experience with a series of recommendations to mitigate from anything similar happening in future.  These findings have been accepted both by the Minister and the RQIA. The department has duly published an action plan showing how it is working through them.  

Mistakes, some serious, were made, and the report finds that all parties to the review - the Department of Health, the RQIA Acting Chair and Board, and RQIA Executive Team demonstrated failings.

But it also states: “Many of those interviewed as part of this Review went above and beyond what has ever been expected of them and undoubtedly saved lives in what was (and still is) an extremely challenging environment.”

And: “there is no doubt that the pandemic, and the speed of decision-making in the midst of the pandemic, was the primary cause of this crisis. It is important to recognise that these were unique circumstances without precedence for all concerned. The pace of decision-making during the period from March to June 2020 was frenetic and it is not surprising that there were weaknesses in communication and some of the processes and procedures were different than in normal times.”

The report concludes however that “this crisis could not have happened if the Department and the RQIA had had the basics of good governance in place - clear roles, well established and functioning relationships, clearly understood lines of communication, reporting and accountability etc.”

And that: “the governance framework of the RQIA is confused and contradictory, and does not comply with best practice. This was a major contributory factor in the problems that emerged during the pandemic.”

Here we enter the complex realm of the responsibilities of arms-length bodies.

The legislation which set up the RQIA is clear.

It states that the RQIA is a body corporate comprising the chair and board members. Therefore the board is the RQIA.  It is an independent, arms-length non-departmental body (ALB) but the department has the right to issue direction and make regulations.

ALBs are not fully independent. The relevant Minister, in this case the Health Minister is accountable to the Assembly for not just the policies, decisions and actions of his Department but also each of its Arm’s Length Bodies. He or she also decides on just how independent it should be.

And the chair of the RQIA is appointed by the minister and accountable to him.

 The chief executive is an employee of the board, but as accounting officer of the RQIA also has responsibilities to the Permanent Secretary of the Department.

The department ensures that the ALB is adequately briefed about the Minister’s policies and priorities monitors its activities and performance on behalf of the Minister.

Specifically the Department prepares a formal document called the Management Statement and Financial Memorandum (MSFM) which sets out the relationship between the ALB and the Minister and his officials.

And it is here that we encounter the root of some of the confusion around governance.

The report states: “the MSFM and the ALB Sponsorship Handbook are substantially flawed – in particular, they fail to reflect the primary accountability of a Chief Executive to his/her own Board and place the emphasis on the secondary accountability of the Chief Executive to the Department (as Accounting Officer).

“This distortion of roles and general undermining of the Board’s role in the MSFM is further illustrated in the RQIA Chair’s letter of appointment (2014) which states that: “The Non-Executive Chair of RQIA reports directly to the Chief Executive of RQIA”.

The report concludes: “The RQIA Board and Chief Executive The Board’s role, as described in much of the RQIA’s core governance documentation, is more akin to that of an Executive Agency or a Departmental Board (i.e. advisory in nature) rather than the pivotal governance role of the Board of an Executive NDPB and ALB.”

The RQIA may not be the only ALB with such a fundamental flaw in its governance framework. Much of its framework flows from governance documents issued by the Department of Finance so the problem may be more widespread, affecting other bodies, and not just in the Department of Health.

And to compound all this there is nothing in the framework which gives the Minister a specific role in the oversight of the RQIA, which creates a very obvious problem not just in the accountability of the chair to the Minister but also a democratic deficit in his accountability to the Assembly. The report notes that most of these papers were drawn up at the time when there was no Assembly or Minister in place, which perhaps explains the omission.

Given all that subsequently unfolded it is easy to see how this confused and even contradictory governance documentation contributed to the crisis.

Most of the decisions made – redeploying the chief executive, ramping down the inspection regime, making the RQIA as a central point of contact for care homes during the pandemic, for example, all made sense – but it was not the decisions per se, but the lack of direct consultation which aggrieved the board.

And the acting executive who was the board’s employee yet not appointed by it was, according to the report: “inexperienced and was thrown in at the deep end in the middle of a crisis. He was provided with no proper induction training or any other preparation for the role.

It concludes: “It is the opinion of the Review Team, and several others interviewed during this Review, that he failed to understand the roles and responsibilities of a Chief Executive and his accountability to his own Board.”

This whole episode demonstrates once more the fundamental importance of good governance to all organisations.  Even with highly professional and highly motivated people things can go wrong without absolute clarity around their roles and responsibilities including who they are accountable to and clear lines of communication backed by well-established and well-functioning relationships.



Join the Conversation...

We'd love to know your thoughts on this article.
Join us on Twitter and join the conversation today.

Join Our Newsletter

Get the latest edition of ScopeNI delivered to your inbox.