Do the current governance structures enable the implementation of the NHS Long Term Plan? A view from the board
22 November 2019
In the past NHS organisations have shown agility at implementing prescribed models of governance, ensuring that they work locally while aligning with the demands of their regulators. The new agenda of integrated care systems (ICS) that deliver system wide, regional and local collaboration between partner organisations, brings a plethora of new challenges including juggling increased joint commissioning, fostering new working relationships and the introduction of Primary Care Networks.
Our recent survey of NHS Non-Executive Directors (NEDs) sought their views on how governance is currently working, what are their priorities for governance under the new system approach and how can some of the resulting challenges be resolved.
So, what did we find out?
We asked NEDs if the governance of the ICS their organisation sits within positively supports the delivery of the NHS Long Term Plan (LTP). Only 27% of respondents felt this was the case.
Respondents saw inter-organisational issues as a major challenge to the delivery of the LTP. The number of organisations, each with their own boards and statutory responsibilities can mean that organisations behave in ways not aligned to their system’s strategy. Until the legislative change outlined in the LTP to allow new organisations to be created is introduced, there is a real risk that systems will not make meaningful progress in implementing the LTP due to ineffective system governance and a lack of clarity as to who is accountable, how decisions are made and how systems are regulated.
As there will not be legislative change in the short term, systems must establish ways of working that deliver the objectives of the LTP but that also allows them to deliver the statutory requirements of their own organisations. Although this will look different for each system I believe that they must all consider not only structures and processes but the behaviours and culture required to be effective.
When asked about the governance arrangements for their regional system, most respondents were ambivalent about whether they positively support the implementation of the LTP.
Of particular challenge is financial accountability across multiple organisations. Shared control totals are driving more collaborative behaviours in some systems, but in others they have reduced the contractual levers historically used to drive operational and financial performance. There were also concerns surrounding clinical staff buy in given the pressures on the clinical workforce at the current time.
As the NHSI/E regional structures and operating model bed in it is vital that the regulatory framework supports system working and governance so that system solutions drive the required behaviours to deliver the LTP.
Unsurprisingly, most respondents (68%) told us that the governance structures within their own organisation enable implementation of the LTP.
The emphasis in recent times on good corporate and clinical governance within individual NHS organisations is reflected in the responses we received. Board members are more comfortable in their understanding of governance and what ‘good’ looks like at a local level.
When making comparisons with responses to the previous questions it is clear that, whilst at a local level there are established structures and ways of working, at a regional and system level these are still embryonic and hampered by a lack of legislative change. In addition, NEDs are more likely to have greater visibility and clarity on governance in their own organisations than governance at a system level impacting their view on how effective system governance is.
In advance of legislative change this needs to be remedied to ensure NEDs of individual organisations have adequate clarity on system solutions and system governance to ensure they can support the system delivery of the LTP through their individual organisation governance processes.
How can NEDs support the resolution of these challenges?
There is unlikely to be a change to legislation in the short term. Consequently, organisations, systems and regions must find a way to collaborate and deliver the LTP whilst continuing to meet their own statutory responsibilities.
Ultimately each system is unique, meaning no one structure will meet every need. However, the key principles of good governance are shared across all systems, particularly those aspiring to high performance. We view these components as crucial to ensuring that governance is a key enabler to system working.
Look out for our next blog on NEDs views on technology and read our previous blog on the regulatory approach.