Effective governance is more important than ever before in health and social care provision. Every organisation faces close regulatory scrutiny of the robustness of their governance arrangements and finds them tested on a day-to-day basis by the practicalities of delivering care in a complex and changing operating environment. These include an increasing readiness on the part of stakeholders to challenge changes to services by way of judicial review; developing, implementing and complying with robust, legally-compliant governance arrangements is key to minimising the risk of such challenges. But creating such arrangements for an integrated service, or extending or transferring them to cover integration arrangements, tends to raise a number of risks and practical challenges.
A clear vision of the governance for an integrated arrangement must be at the heart of the project and should be addressed from the start. It's not an add-on, but something which is fundamental both to the legal robustness of the arrangement and for its prospects of success in practice. Discussion of governance structures allows everyone involved to engage properly with fundamental issues about the nature and extent of the tasks which are being integrated and decision-making within the new arrangement focussing on the practicalities.
- What are the responsibilities of the organisations and individuals involved?
- Who will people report to?
- Is there sufficient capacity to govern, lead and manage the integrated service?
- Who has authority to take decisions on particular matters?
- How will conflicts of interests be addressed where they arise?
- Who can and should receive particular information?
- What happens if there are disagreements? How does this arrangement fit into the wider health and social care framework in its area?
- Who is paying for what?
Early discussions about governance can be difficult, as initial broad visions are put through the filter of these practical questions. Often these discussions can expose differences of expectation or understanding about the project, or potential problems which hadn't previously been identified. Dealing with these issues at an early stage is essential, otherwise legal, relationship and practical problems will be encountered further down the line.
It may be helpful to work through these discussions with appropriate professional advice. This will give all of the parties clear legal and practical parameters to navigate within and to shape the governance arrangements. We often find that this requires all parties having a clear understanding of the statutory functions and governance frameworks of those they are collaborating with (whether NHS body or local authority). In particular, the legal framework for local authority governance differs substantially from that of NHS bodies, and Health & Wellbeing Boards occupy an unusual place within that framework, which means their place in an integrated governance structure needs to be carefully considered.
A related issue is the identification of success measures for a project: what outcomes are sought and how will the financial and wider success of the project be measured? If these can be clearly defined, they can operate as touchstones which help map solutions to more detailed issues around governance of the integration project and governance structures for new service delivery models.
Where integration creates multi-disciplinary teams, there is a particular need to establish clarity around service standards and responsibilities within the team. Even where integration brings together professionals working within the same clinical framework, there may be long-standing differences in interpretation or approach within that framework. Issues will be exacerbated where integrated teams or their managers are having to work across different sites and with different systems. Careful advance planning is needed to ensure that potential risks to service users are tightly controlled by appropriate operational arrangements which are in place, and well-understood when integration goes live.
And it is essential to identify and manage risk more generally if the integrated service is to be a success. It is likely that risks will need to be managed collectively among the parties, but some of them may impact on a particular party more significantly than the others, so risk management arrangements will need to take account of that. Early agreement on the approach to risk management can help to address these issues, and to assure regulators.
It is also important to understand – and not to underestimate – cultural differences between the NHS and local government, and between different parts of the NHS (or even just inevitable differences between any two different organisations or teams which have been led and managed in different ways). Advance consideration needs to be given as to how to bring teams together and prevent relationship issues from affecting the success of an integration arrangement. Clarity about how governance will work in the new arrangements, including roles, responsibilities and decision-making processes, is likely to help with this – as is focusing on the vision for the project and the improvements for service users.