Commentary: Good governance is patient-centred

NHSScotland’s former CEO Paul Gray to address challenge of when cultures eat strategy for breakfast

Thursday 18th April 2019

Scotland’s former NHS chief executive says strong governance, rooted in quality, is good for patients – but it’s the culture of the organisation, and its impact on individuals and teams working directly with patients, which makes the biggest difference.  

Mr Gray is to lead a workshop at the Quality Governance Collaborative’s first annual conference next month addressing how quality governance can impact upon patient outcomes. Alongside him will be John Brown, chair of NHS Greater Glasgow & Clyde, and author of the NHSScotland report 'A Blueprint for Good Governance'. asked Mr Gray whether Scotland’s globally recognised Patient Safety Programme might be an example of getting governance right?

PG: The Scottish Patient Safety Programme has been running for over 10 years and has made a very significant difference. If you look at some of the measures, such as hospital standardised mortality ratio, you can see the direct impact that the Patient Safety Programme has had on reducing in-hospital mortality. A study published in the British Journal of Surgery on 16th April 2019 shows a reduction of over 36% in surgical mortality linked with the implementation of the WHO surgical checklist via the Patient Safety Programme. It is also, I think, about taking some pretty important steps to keep the focus on the patient. We really have moved a long way in terms of promoting and embedding the idea that person-centred care is essential to the delivery of effective services.

h&c.s: Do you think that the lessons from the Programme have been as much about culture as a set of rules?

PG: There is a saying in improvement circles, and possibly wider, that ‘culture eats strategy for breakfast’ – and that’s true in practice. Culture, put simply, is The Way We Do Things Here and, if the way we do things here is to put the patient at the centre and to pay attention to quality and safety and person centredness, then that is bound to bring about measurable improvement. You do need to underpin this, though, with analysis and data. There needs to be an evidence base for what you are doing, and an evidence base to tell you that the changes that you are putting in place are having the impact that you wanted them to have.

h&c.s: What role does leadership play in achieving the sort of culture change that can make a difference for patients?

PG: Leaders have to be enabling and empowering. The real change happens at the point at which there is contact with the patient, and senior leaders in organisations perhaps are less involved in that than the front line staff – they are the ones who are absolutely critical to the success of anything like the Patient Safety Programme. So, it is important for leaders to enable front-line staff to engage with the programme, to understand it and then to put it into action, because all change is local. Change does not work well if it comes from the top. Change works well if it is locally designed and locally implemented.

h&c.s: What then are the governance lessons from a huge and complex organisation like NHSScotland?

PG: The senior leadership of organisations should have a responsibility for setting the strategy and being accountable for its delivery. In the NHS, ultimately government ministers set the strategy but then the senior leaders are responsible for delivery, and they should be accountable for that. But they also need to make space for the change to happen on the front line that will genuinely benefit patients, their carers and their families in ways that are measurable and material and produce better outcomes.

h&c.s: Do you think that governance has become a bit of a dirty word and that, when we talk about quality governance, some people feel slightly threatened by that?

PG: I could understand that if governance is just the introduction of greater complexity and more rules and increased bureaucracy, then people are quite right to be sceptical about it and fearful of it. If, on the other hand, governance is about ensuring there are proper quality systems and standards in place, if it’s about holding people to account for delivering against the quality standards that are set, if it’s about identifying areas of good practice so these can be shared and spread and if it is about ensuring that when things go wrong there is transparency and openness about that, then governance is a positive opportunity. So, it depends how you play out the governance and it depends on the commitment, of those who are responsible for the governance, to ensuring that quality and patient safety are at the centre of all that we do.

h&c.s: If there is one message that you hope will land with your audience at the first Quality Governance Collaborative seminar what would it be?

PG: What I would say is that governance is here to help us to be safe, person-centred and effective – and that is what NHSScotland is about.


The Quality Governance Collaborative’s first annual conference is taking place at the Royal College of Physicians of Edinburgh in Queen Street, Edinburgh, on the 10th May. is the College’s media partner for the meeting. Follow us on twitter for interviews, updates and more. For further details and to book your place, please go to