The health and social care white paper - How to maintain ‘organisational governance’ in ‘a shared system’ context

by David Morris Health Services Sector Leader

Email +44 (0)7841 784180

A new white paper has set out the Government’s intentions to improve health and social care for everyone by building on the remarkable collaborations we have seen throughout the COVID-19 pandemic. It suggests a path of evolution rather than revolution, and it emphasises the duty to collaborate. However, there is much that it doesn’t explain – indeed it leaves some big questions unanswered.

PwC invited a cross-section of senior leaders from across the NHS to a roundtable event to reflect on the implications of the proposed legislation. These discussions highlighted concerns about how the system would work.

Old habits die hard, and after 20 years in some cases of being a foundation trust (FT), the notion of shared system governance for finances and patient tracking lists (PTLs) – as proposed in the new white paper - is a difficult concept to grasp, especially if you are a high performing trust.

Those who were around at the time of FTs being introduced will know there was a marked improvement in trust governance, which might have been spurred on by Monitor’s assessment process or the realisation that the model contained both a threat and, probably more attractive at the time, a real opportunity.

Most FTs had and still have budgets that their boards steward in the hundreds of millions of pounds, they treat thousands of patients, and employ thousands of staff. And, generally they do it remarkably well with little remuneration when compared to private organisations of similar scale.

So, when it comes to now managing a budget across a system with financial constraints and thousands of people waiting over 12 months for care, the prospect of boards sharing these challenges can look daunting.

If a board has managed its own organisation well, what, on the surface of it, are the incentives to take on shared risk with others? It’s not easy to indemnify in the eyes of some trusts, and their consequent mindsets can and do remain focused on their own assets and challenges despite nodding along to wider system working. This is not an easy mindset to shift.

Yet the benefits of whole system working and place-based budgets, managed directly by providers of care, working collaboratively can be seen in places such as Canterbury, Alzira, and Jonkoping. These systems tend to out-perform others in terms of all three aspects of the triple aim - better health, better care, better value.

But we mustn’t ignore the fact that sound stewardship and governance of the constituent parts is a precursor to high performance of the system. So, how do we build in the best of both worlds into our mindsets and new operating model?

Working with some of the emerging best-in-class integrated care systems (ICSs) across the country, the answer seems simple:

  • take the principles of great FT governance (like excellent staff engagement) and build them into your new system governance;
  • use carrots, not sticks to reward success and use earned autonomy for providers working together rather than restrict capital as a threat;
  • choose leaders who are capable of sound organisational management but are also collaborative and inclusive by instinct.

If you have any thoughts, or if you would like us to talk to you or your senior team or board, please get in touch and please read our further three blogs on the white paper.

by David Morris Health Services Sector Leader

Email +44 (0)7841 784180

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