Governance review calls for greater accountability in Manx Care operations

The report highlights inconsistent meeting practices, variable Board contributions, and absent performance measures for Shared Services.

An independent audit of Manx Care’s leadership and governance has found the organisation has made progress since its creation in 2021, but still faces significant challenges in strengthening how it plans, operates, and holds itself – and its partners – to account.

The review, carried out by the Management, Internal Audit Agency (MIAA), examined the effectiveness of the Board and its committees, and the alignment of decision-making to the mandate set each year by the Department of Health and Social Care (DHSC).

While auditors said Manx Care’s governance structure is “reasonable”, they concluded that its purpose and operation need clearer focus – particularly in ensuring strategic priorities are embedded throughout the organisation’s oversight and assurance processes.

Mandate and strategy

The report found a lack of shared understanding across the Board of what the annual DHSC mandate represents, and highlighted a historic disconnect between the mandate and the funding allocated to deliver it. This, it said, has hindered the development of longer-term strategic planning, with the focus often falling on short-term operational delivery.

Auditors recommended that Manx Care and the DHSC work together on measurable mandate outcomes, realistic costings, and the creation of three, five, and 10-year strategies – potentially with public involvement.

Board and committees

The Manx Care Board – made up of eight executive and eight non-executive directors – was described as broadly balanced in skills, but with gaps in clinical representation and DHSC attendance. Two non-executive vacancies remain, with a further two expected in the next year.

The review said levels of contribution and constructive challenge at Board and committee meetings were variable, with over-reliance on a small number of individuals, particularly the chief executive and chair.

Committees were found to meet more frequently than best practice, and in some cases lacked clear alignment to strategic priorities. Workplans and Terms of Reference often did not reflect mandate deliverables, and assurance reporting from sub-committees was inconsistent.

The quality and timeliness of Board and committee papers was identified as a persistent problem, with late submissions, incomplete information, and excessive verbal updates reducing the effectiveness of meetings.

Shared services and decision-making

The review highlighted difficulties in holding Isle of Man Government Shared Services to account, due to an absence of agreed performance measures. Manx Care is legally required to use these services for areas including finance, HR, IT, estates, and legal support.

Auditors also recommended introducing a formal Scheme of Reservation and Delegation to clarify decision-making responsibilities between Manx Care, DHSC, and Treasury.

Risk management

Although Manx Care’s risk management framework has developed since 2021, MIAA said the Board Assurance Framework (BAF) needs a “reset” to better align with strategic priorities and include clear action plans for closing gaps in control and assurance.

It called for greater ownership of the BAF by executive directors, more consistent scrutiny of risks at committee level, and training to improve its use in directing Board discussion.

Conclusion

In total, the review makes more than 40 recommendations, ranging from improving meeting discipline and Board development to strengthening relationships with DHSC and embedding long-term planning.

Manx Care’s Chair, Dr Wendy Reid, said the review was an opportunity to reflect on progress and identify ways to “better support transparency, accountability, and strategic oversight” in the Island’s health and care system.