The Governance Dividend - the return from the early days of integrated working
13 February 2019
It’s a universally recognised mantra that joining up services can go a long way towards improving patient care. The NHS Long Term Plan reiterates its commitment to the integration of our public services, and the ambition to have Integrated Care Systems (ICSs) across the country by 2021.
This integration agenda provides us with an opportunity to transform the landscape of health and social care in our country, and, if implemented well, will be a key factor in securing long term financial sustainability within the NHS and social care.
To ensure success, these programmes require an investment of time, attendance and manager commitment from the current sovereign organisations in order to work through and develop plans.
Many CEOs are under pressure from their boards to justify the time and energy spent in these new governance structures, especially when the delivery challenge ‘back at base’ remains high. We are seeing this first hand with a number of organisations we work alongside reporting difficulties in combining the day job, to which they remain statutorily accountable, with committing resources to the structures of integration (which have no statutory basis).
Finding value in new ways of working, particularly at inception can be difficult, as outputs are often less tangible and more qualitative in nature. Often, the direction of travel can be as important as the weekly deliverables from the work. Articulating the value of this journey, however, is rarely attempted.
A NHS Trust CEO recently had a choice between attending a system-wide development workshop, or a meeting of the Board. The CEO chose to attend the system meeting, on the explicit understanding that the Board would see the tangible outputs.
Whilst these were not traditional output measures, the CEO summarised them as:
- a statement of joint intent;
- a roadmap for decisions to be made;
- a common vision of the system end-state;
- time with other CEOs to thrash out common issues and solutions;
- a clear benefit for the CEO’s home organisation in shaping the future
This demonstrates how organisations can document the process and show the benefit the investment in governance is bringing. Furthermore, integration must be underpinned by the right behaviours including adaptive, resilient and inclusive leadership, committed to driving integration.
In order to help organisations categorise these new ways of working, we have compiled a guide to this process, which we call the Governance Dividend. Classically, a dividend is defined as a regular payment by an organisation to its investors out of its profits - it is the return on investment. A Governance Dividend is similar; those investing in governance processes to address new ways of working should always be looking for a return.
As illustrated below, in practice, the dividend for system working is realised in stages:
As with financial dividends, initial and ongoing investment is required. This will primarily be in the form of time, knowledge and financial commitment and, with the right balance of these, a reward should be expected - a Governance Dividend.
This can take a number of forms for different programmes of work, however there are consistent categories of return that, when working well, will be realised.
In the short term, relationships between the various parties will form and develop as participants work together. This will allow a sharing of insight and learning, immediately adding value to the partner organisations. Strategic direction can also
start to be set, setting intentions that will benefit the organisations and the communities they work in.
By building upon these foundational returns, operational alignment can be secured in the medium to longer term as partners make strategic and operational decisions that take coordinated objectives into account.
Through the Governance Dividend, system-wide efficiencies and coordinated place-based transformations are achievable, and, crucially, will support the objective of driving greater integration, delivering clear benefits for all the individual organisations involved and their communities.