By Mark Green, Director Board Advisory
The NHS Long Term Plan (LTP) and the development of STPs, ICSs, ICPs and now PCNs (see Figure 1), not only makes for a mouthful of acronyms, but also raises the prospect of a governance headache. While the LTP requires every NHS organisation and their local partners to become part of a geographically-based ICS by April 2021, and recognises that it’s possible to implement the necessary changes without primary legislation, it also acknowledges that legislative change could make implementation easier and faster.1 However, there are currently limited signs of any primary legislation being introduced in the short to medium term to support and guide the shift in health and care policy.
Figure 1.The main stakeholders in the Integrated Care System
In this latest in our series of blogs exploring the various challenges facing ICSs, we draw on our experience of setting up and constituting new, enabling, governance structures in response to national policy on new models of care, to highlight some of the practical design principles and lessons to consider when navigating this changing landscape.
The emerging governance landscape
Across the NHS, we are seeing new ways of working starting to emerge. These include the establishment of hospital groups, mergers of health commissioners, the development of joint governance and management arrangements across multiple health and care organisations and examples of decision-making groups on a place-based footprint. Nevertheless, to make these initiatives work, both individually and collectively, clear and effective governance is essential.
One of the greatest governance challenges is how best to ensure that there are clear lines of accountability that balance the legal requirements of individual organisations with the drive to integrate, especially when formal accountability remains with individual organisations and ICS’s have no statutory underpinning.
Importantly, many of these accountabilities start to blur as systems transition to bring together provider and commissioning responsibilities in line with the vison in the LTP. There is a need therefore, to agree where to draw the commissioning and provision line both now and in the future in order to actively engage providers in new conversations at both system and place level.
Emerging models of place-based governance include a broad range of stakeholders from NHS commissioning and provider organisations, PCN clinical directors, local authorities and independent and third sector providers, operating in the style of a Board. It is critically important to ensure that this coming together of purchasers and providers does not reduce accountability, and decisions are made in the interests of the patients and populations they serve and not the interests of the professional groups, and organisations round the table.
The ICS also needs to address the role of local authorities, especially given their accountabilities to their elected members, but also their role to both provide and commission services.
Navigating the required changes
Based on our experience to date, we have outlined some key design principles and lessons learned to consider as organisations assess and agree what will work for each local circumstance:
- Fully define what you are attempting to achieve: as the author Stephen Covey once said in his book The 7 Habits of Highly Effective People, ‘start with the end in mind’.2 Whilst we would never advocate governance as an after-thought, there is a need to define what you are attempting to achieve before designing appropriate governance to wrap around your endeavour. In our experience, those systems making real progress have focused their efforts on a small number of priorities. Defining a compelling case on how integration will benefit citizens, residents and patients is important, and it is critical in answering the question of why the system is bigger than the sum of its parts. The original Greater Manchester Devolution Memorandum of Understanding from 2015 defines a clear purpose ‘to ensure the greatest and fastest possible improvement in health and well-being’. The ‘Wigan Deal’ highlighted in our report on population health management is based on a citizen-led approach to transformation.3
- Continue to build trusting relationships amongst partners and organisations: trust and respect are critical enablers of collaborative and partnership working. We often find the absence of these attributes manifests in a pre-occupation with ‘governance’. And, as important as structure and wiring diagrams can be, systems that continually revisit their ‘governance arrangements’ are often masking deeper issues. Equally, language and a common ‘lexicon’ among partners is critical to building trust. The opportunity for misunderstanding and confusion when describing the ultimate beneficiaries of integrated care are evident – for example, should we use citizen, resident, patient or service users? On a more positive note, our experience is that true co-production engages partners, creates clarity of purpose and, reduces the likelihood of those involved in the design and in owning the output, objecting to change.
- Consider conflicts and competition: challenge is highly likely if there are attempts or perceived attempts to blur the legal provision and commissioner divide. Maturing systems are increasingly comfortable in navigating this territory, but there is a fine line between involving providers in commissioning discussions and unintentionally allowing them to direct commissioning plans, intentions or service specifications. Transparency in any governance structure with effective management of conflicts of interest is necessary. Equally, the chosen arrangements must address legal requirements around competition, particularly where data or information is shared that could be perceived to give one party an advantage or be seen to limit choice. We have seen some attempts centrally to manage and provide guidance, most notably in cancer and now in mental health through the provider collaborative. The development of the regional Cancer Alliances through the vanguard programme also demonstrates what is possible in this space.
- Do not lose sight of who is ultimately responsible and ensure appropriate delegation: it is not possible to work through every eventuality, and there will always be unintended consequences, but the adopted governance structure and arrangements must avoid circumventing broader legislation. Good governance dictates that oversight and challenge of significant changes by executives and non-executives sitting on Boards and governing bodies is essential. You are also likely to receive challenge, particularly from local interest groups, if the perception exists that you have bypassed appropriate scrutiny. While the delegation to individuals is an important mechanism for making these new arrangements work, it is a balancing act to achieve. In mitigating these risks, we are advising clients on the creation of a range of joint board and committees arrangements with delegated authority as well as joint appointments and management team arrangements to enable effective governance.
Despite the challenges, governance has a critical role to play in enabling the success of integrated care systems. There are various routes and mechanisms to successfully and safely navigating these waters and making this new world of collaboration and integrated working a reality. In our opinion, clarity of purpose, defining the vision with relationships built on trust are key to steading the ship, whilst remaining within the current legislation. Ultimately, with no basis in law, ICSs depend on a collaborative approach to leadership and a willingness on the part of the organisations involved to work together, including giving up some of their own sovereignty for the greater good of the populations they serve. By adopting the design principles discussed above, systems can evolve and adapt their governance within the existing statutory framework and establish the foundations for an effective ICS.