Fixing governance is key because clear lines of accountability are so important, given the amount of public spending involved in integrated care systems. One challenge is that formal accountability presently remains with individual organisations, and ICSs have no statutory underpinning. This makes it more difficult to create clear governance systems and depends on the goodwill of participant leaders. Also, accountability to local people and patients is under-developed in some places. If local authorities are to be fully involved in ICSs, their role in this must be addressed and their different accountabilities with elected members must be considered. If national bodies see ICSs as ‘load-bearing structures’ – taking on more responsibility for finances and performance – then clear and effective governance is essential. My experience suggests that NHS chairs and non-executive directors, with some coming from commercial backgrounds, often feel this more strongly than executive colleagues.
However, designing an elegant organisational committee structure and decision-making processes and powers does not in itself constitute progress towards transforming services for patients or staff. As we have seen from the first year of integrated care systems, what works is what works locally. Therefore, governance systems must be developed by leaders invested in the success of integrated care in their individual areas. That being said, there are lessons to learn and some common themes in what has been done so far.
First, fixing a governance system is not a one-step process but evolves over time. As some of the most well-developed systems, such as that in Greater Manchester, have found, governance develops through collaboration in practice – what is fit for purpose at the start is not necessarily so six months later. Other ICSs, such as Frimley Health, have found that prioritising changes to what is currently being done ahead of creating a governance structure has been a better way forward for them.
Second, what needs to be done by an ICS and what should be done at the level of place – the integrated care partnership (ICP)? With the underpinning theory that higher engagement and the best decision-making occurs as close as possible to where services are delivered, it has been suggested that around 80 per cent of decisions should be taken at the level of place and 20 per cent at the wider system level. If this is accepted overall, then there is a strong argument that a governance system created should reflect the same principles.
The net effect of this would be just a thin layer of ICS governance, with most governance remaining at local level. This approach appears to be gaining ground in several systems. In the many conversations I’ve had with those grappling with introducing integrated care, however, there is very strong feeling about what should be done at what level. As this concerns decision-making and ultimately power and influence, this is unsurprising – but it is also why agreeing the approach to governance remains a priority.
Third, some leaders have commented that ICS governance is just an elaborate way to reintroduce health authorities – which, interestingly, are now cherished as I cannot recall from when they existed. Perhaps absence truly does makes the heart grow fonder! My own view is that ICSs are not a new form of health authority, because integration now occurs at the level of place when in the past it was at the higher level of the strategic health authority (SHA). Before the abolition of SHAs in 2013, separate providers and commissioners could and did work separately at place level, so the responsibility for co-ordinating the disparate elements fell to the wider NHS system. This responsibility now sits at place level, with organisations feeling they have a duty to integrate, so a thinner layer of overarching governance at the system level could work. SHAs were also a key vehicle for driving a top-down approach to management of the service. In contrast, ICSs provide an opportunity for this to be more bottom-up and based on collective decision-making – even on matters that would in current models be the preserve of a single organisation. How all of this will work in practice, however, remains to be seen.
Innovations around governance systems are being pursued up and down the country. In Cumbria and Croydon, for example, discussions are underway between clinical commissioning groups and providers about coming together at place level to facilitate further integration by removing the purchaser/provider split we have known for nearly 30 years. This again will create an important role for ICS governance to hold local integrated systems to account. Governance systems will need to mitigate any concerns that the coming together of purchasers and providers creates the risk of reduced accountability and ultimately decisions being made in the interests of professionals and organisations and not the people we are here to serve.
The topic of governance in integrated care is developing fast and there is much more to be done to create systems that support rather than undermine integrated working. We need also to develop governance that provides the accountability required to assure patients and the public that the necessary checks and balances exist. It is going to be quite a ride.