In the NHS, governance is designed for safety and accountability — and rightly so. But the side effect is delay. Proposals get written into 60-page business cases, circulate through multiple committees, and wait months for a slot on an ICS board agenda.
Meanwhile, frontline staff still face the same problems they flagged six months earlier.
Why Governance Fails Transformation
Too slow: Decision cycles take months, while digital change needs weekly adjustment.
Too heavy: Steering boards focus on risk registers, not frontline blockers.
Too abstract: Papers describe plans; frontline staff need quick fixes.
Result: frontline teams disengage, and transformation feels like paperwork rather than progress.
Tools for NHS Teams
Decision Escalation Canvases
Complex NHS decisions often get lost in endless papers. A one-page canvas can standardise the essentials:
| Section | Prompt |
|---|---|
| Clinical Problem | What issue are staff/patients experiencing? |
| Proposed Solution | What change is being recommended? |
| Risk Category | Green (<£50k, workflow/config) / Amber (moderate, patient impact) / Red (structural/capital) |
| Sign-off Required | Sprint huddle / Clinical Safety Officer / ICS Board |
| Costs & Benefits | Estimated financial/resource cost vs expected benefit |
| Risks & Mitigations | Patient safety, regulatory, reputational risks and mitigation plans |
| Next Steps | Who needs to act, by when? |
| Escalation Route | Pathway huddle → Programme Board → ICS Board |
This keeps decisions transparent, consistent, and auditable.
Sprint Governance
Borrowed from agile delivery, sprint governance means:
- Weekly or fortnightly huddles at pathway level.
- Focus on progress and blockers, not 30-page papers.
- 15-minute stand-ups with empowered decision-makers.
The goal: unblock frontline issues in days, not months.
Evidence in Practice
NHS Vanguard (Enhanced Discharge Teams): Weekly governance huddles authorised small operational changes (equipment provision, transport arrangements) within two weeks. Result: discharge delays cut by ~20%.
Kaiser Permanente (US): Rapid cycle governance forums resolved ~80% of routine workflow issues within <2 weeks, while escalating high-risk changes to central boards.
Both show that when low-risk issues are treated differently, outcomes improve without undermining accountability.
Safeguards for Agile Governance
Compliance: Agile governance supplements, not bypasses, statutory duties. CQC standards, DCB 0129/0160 clinical safety, and statutory consultations remain mandatory.
Risk Categories: Use a 3-tier framework:
Risk prompts are built into every decision canvas.
Decision Canvas: Standardised one-pager captures clinical problem, solution, risk category, required sign-off, costs/benefits, risks/mitigations, and escalation route.
Escalation SLAs: Sprint huddle → decision in 48 hours. Programme board → decision in 5 working days. ICS Board → decision in 6–8 weeks maximum.
Authority: Empowerment comes from formal board-level delegation (via SFIs/Scheme of Delegation). No shortcuts.
Resources: Each canvas = ~1–2 analyst days. Sprint governance needs ~0.5 WTE PMO/analyst per pathway.
Board Oversight: Quarterly summaries of sprint decisions go to ICS boards, with exception reports for Amber/Red escalations. Full transparency maintained.
Cultural Fit: Governance is slow for good reasons — past failures. Confidence grows by piloting with low-risk Green decisions first, then scaling scope as trust builds.
The Economics of Delay
When discharges are delayed because a decision waits for the next quarterly board:
Many of these delays are solvable with small, rapid decisions (e.g. community transport, IT fixes).
Agile governance makes these savings visible and real.
Takeaway
NHS governance protects patients, but it doesn't need to paralyse progress.
By using Decision Escalation Canvases and sprint governance, ICSs can preserve statutory accountability while unblocking frontline issues quickly.
Agile governance bridges bureaucracy and delivery — faster, safer, and more credible.