Non-executive directors and integrated care: time to think system

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It’s hard to keep track of the changing vocabulary of sustainability and transformation plans, accountable care organisations and, most recently, integrated care systems. Even as a supposed expert in health and social care, it can be hard work keeping up with the latest policy buzz phrases. For non-executive directors (NEDs) of NHS trusts, who hail from a range of backgrounds often outside the NHS, keeping up can be even harder. This might help to explain why NEDs generally do not seem to have played much of a part in sustainability and transformation partnerships. Yet at a time when the NHS is facing arguably the biggest challenges in its 70-year history, the need for NEDs to understand these changes and what they mean for their own role and responsibilities has never been greater.

NEDs play a critical role in bringing an independent perspective to trust boards and in holding the executive to account. Reflecting on my own experience as a NED of an acute and community trust over the past three years, and aligning this to emerging messages from the Fund’s work in supporting the 10 places that are developing integrated care systems, I would like to offer some clear pointers for NEDs in thinking about their role and contribution.

The most obvious message for NEDs is to ‘think system’. The challenges facing the NHS – arising from changing needs, rising demand, pressure on money and workforce – are now so great that organisations cannot meet them on their own and need to collaborate across organisational boundaries.

The challenges facing the NHS – arising from changing needs, rising demand, pressure on money and workforce – are now so great that organisations cannot meet them on their own and need to collaborate across organisational boundaries.

As Chris Ham has explained, behind the changing vocabulary most of the initiatives are really about integrated care – how different parts of the NHS work together and, with local authority and third sector partners, better co-ordinate care for individuals and improve the health of their local populations. The language used is far less important than ensuring each local system has a clear vision and plan. But as yet sustainability and transformation partnerships and integrated care systems are not legal bodies in their own right so the fundamental responsibilities and accountabilities of trust boards are unchanged. And regulation is still based around separate organisations, although the Care Quality Commission’s programme of local system reviews is a welcome step in the right direction.

NEDs’ main purpose is to ensure effective oversight of how effectively their organisation is ensuring the quality and safety of care, meeting constitutional targets and achieving financial balance.  Triangulating these expectations is massively challenging as our own quarterly monitoring reports continue to show. NEDs are expected to seek assurance from executive directors, whose ability to provide that assurance has never been tougher, which represents a massive stress test of relationships within Boards between NEDs and Executive Directors. Getting the right balance between support and challenge calls for sound and mature judgement. Boards that can withstand these pressures and perform well are likely to be those that have invested time in nurturing relationships through board development programmes or other developmental activities.

Jocelyn Cornwall’s letter to a friend offered sage advice to NEDs that is even more relevant today. Recent research from Birmingham University and the Nuffield Trust highlights the value of a ‘restless board’ that seeks constantly to compare itself with others and find ways to improve. And a clear lesson from efforts to achieve integrated care over the past 40 years is how much progress is driven by building trust and collaborative relationships rather than through organisational structures and governance.

And a clear lesson from efforts to achieve integrated care over the past 40 years is how much progress is driven by building trust and collaborative relationships rather than through organisational structures and governance.

As different forms of integrated care partnerships evolve, all boards need to consider how they develop a dual focus on the performance of their local system and that of their own organisation. It remains unclear how far this can be achieved within current governance responsibilities without legislative change.  The Health and Social Care Act 2012 places a general duty on boards, and on directors individually, ‘to act with a view to promoting the success of the corporation so as to maximise the benefits for the members of the corporation as a whole and for the public’ (Schedule 7 para 18a of the National Health Service Act 2006 (as amended by Section 152 of the Health and Social Care Act 2012)).

In the new world of integrated care, the benefits for ‘the corporation’ and for ‘the public’ may not be one and the same. This is one of many ambiguities for boards in trying to be collaborative within a legal framework that was designed with a different purpose in mind. There are no easy or immediate answers. In the meantime there is no doubt that as collaborative system working gathers pace, NEDs should spend more time in developing relationships and networks with other parts of their local system as well within their own organisation. Some places are beginning to consider ways of bringing NEDs into the governance structures of their integrated care system, for example by having a NEDs, lay members and elected members group.

Many local system leaders have been heard to say ‘progress happens at the speed of trust’. NEDs are well-placed to bring wider perspectives – and that underestimated resource, time – to help lay the essential foundations of local relationship-building. NEDs of the future may well be judged not by how much time they spend in meetings but by their contribution to the ecology of system relationships.

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