The blind men and the governance elephant

Nicola King, NHS England’s Head of Commissioning Skills for the Commissioning Development Directorate, uses a parable to highlight the work being done to help CCGs:

Image of the parable of Blind Men and the Elephant

Elephant illustration (C) Jason Hunt


THE parable of the Blind Men and the Elephant appears in Buddhist, Jain, Hindu and Sufi teachings.  John Godfrey Saxe (1816-1887) set down the story as a poem in the 19 Century, securing its survival as a secular modern lesson.

There are many versions, but in each one a number of blind men are placed around an elephant and invited to describe it.

The man who stands at its ears says it is like a fan; the man who stands at its tusks says an elephant is like a spear; the man who stands at its tail says it is like a rope – and so on. In most versions of the tale, the men come to blows on the matter before they are able to understand the truth. They are all equally correct – but all completely wrong in any meaningful sense.

The story pertains to so many aspects of our lives that it’s not surprising it has been retold for so many centuries.

It’s been on my mind in recent weeks as I have listened to views from CCG leaders, managers and members of the public from all over the country and internationally.  They have been helping us shape our initial discussion documents in work we are doing to help CCGs develop effective approaches to their governance arrangements that fit their unique structure and aims.

If you ask different people what governance is, you get a multitude of different answers. To some, it is about financial planning – to some, it is about clinical standards – to others, it is about patient safety.

As with the elephant, judgements about what governance is will massively depend of the perspective from which it is viewed or experienced. Without a shared understanding of what our governance is for, what its core purpose is and the way in which it serves our range of different stakeholders, we will end up fighting rather than collaborating in our pursuit of good governance.

So if we can’t agree on what good governance is and what it is for, how can we agree on what good governance looks like?

The first step to answering this question lies in finding out exactly what all our perspectives of governance are – which bits of the elephant we can recognise. Our partners at The Good Governance Institute are currently working through the online feedback we have received from all of you, and pulling this all together into a set of ideas and principles.

In two weeks’ time, we will hold a series of workshops across England where people interested in CCG governance will get together to discuss and develop these initial thoughts into a clear narrative suitable for our  new world of clinically-led, locally-focussed commissioning organisations.

We will have events throughout the week beginning 24 April in Birmingham, Bristol, Leeds London and Manchester – make sure you register to attend the one nearest you.

If you are shouting or nodding at the screen as you read this, there is still time to make your contributions to the debate ahead of the workshops.  Take a look at our site at the CCG Governance website for more detail on how to get involved.

After the workshops, The Good Governance Institute will propose a new language of governance for CCGs that engages with everyone’s perspective, regardless of how they perceive the elephant called Governance, and brings them together positively to fully describe what governance in a CCG is for and how its outcomes should look.

Just like an elephant, the NHS is a huge, complex and magnificent organism, with countless very different systems and processes that must work in harmony together for the whole to operate to its full potential. It operates in a difficult environment, and must maintain the flexibility to adapt to famine and feast, drought and flood.

By working together to understand not just how the different parts of our Governance elephant look, but how they join together to make a collaborative, organic and developing whole, we can build an NHS that ensures our communities always get the highest-quality care and best possible outcomes.

Nicola King

Nicola King is Head of Commissioning Skills in the Commissioning System Development support team.

For the last year she has been leading a programme of work to support the development of CCGs. One of the things that CCGs have been asking for is support to develop governance arrangements that suit the new organisational form of CCGs and which are light on bureaucracy while being rigorous in providing assurance to their full range of stakeholders.

She has supported a task and finish group of the NHS Commissioning Assembly CCG development working group to commission a piece of work from the Good Governance Institute to assist CCGs with this.

Nicola has worked in the NHS for 25 years. She originally trained as a pharmacist and was a specialist in cardiothoracic medicine before moving into general management roles more than ten years ago.

One comment

  1. Christian says:

    This is a great comparison thank you and allow us to drill down in a simplistic manner. Simple is always good. (I do not believe our challenges are complex.) The parable makes one think of why it turned out like it did. What was their initial brief and their independent mind set. It would appear that it was not on teamwork or the bigger picture. Hence the outcome!?
    Regarding CCGs going back to basics the primary focus has to be about “the quality of care”. (The reason the organisation is there for.)
    With various professionals with specific skills, backgrounds and experiences, a team ethos is essential. (Listening, understanding, considering, willingness, open-mindedness, creativity, respect, trust etc. is critical to the group’s success).
    We know the expertise is there and if consistently underpinned by teamwork values and a determined common interest, I believe it sets the stage for a successful organisation and a strong leadership team.