Integrated care boards – why a whole-system governance approach is key

Getting the constitution right is fundamentally important for the good governance of integrated care systems (ICSs), providing a platform for success.

ICSs up and down the country developing their constitutions ahead of the national deadline on 30 November should be mindful of taking a whole-system approach.

The bill requires CCGs to conduct a consultation, although NHSE guidance refers to engagement, and CCGs will propose the final draft to NHSE in Q4. In any event, the draft constitution is a vital document; if it’s not done properly, it could damage system relationships and – even more importantly – affect the system’s ability to deliver against its objectives.

The model constitution sets out the areas that are mandated, and those that are for local design by the ICS. It is no surprise that the issue of greatest interest will be the membership of the integrated care board. As in most structural changes that take place in the NHS, there is often a clamour for representation on what is seen to be the most important meeting, possibly fuelled by anxieties and fears, or a lack of understanding of the different components of an ICS and where important decisions will be shaped and taken.

Model constitution

The model constitution sets out the minimum membership of the ICB:

• chair

• CEO

• two NEDs

• three executive directors: CFO, CMO, CNO

• three partner members: primary care, NHS trust and local authority

The guidance notes set out a number of considerations for ICSs in determining the membership of the ICB, including the following:

• The need to ensure balance of perspectives on the board. This will include, for example, ensuring that the perspectives of all sectors and types of provider within the ICB’s area are taken into account (e.g. acute, mental health, community and specialist).

• The need to ensure that the views and perspectives of patients, carers and the public are heard and included in the board decision-making process, along with those from clinical and professional groups, under-represented communities and different geographical perspectives.

• A board comprising diverse individuals, backgrounds and perspectives that truly reflects the local population will be more likely to make the best decisions for its communities.

• Beyond the composition of the board itself, ICBs should ensure there are mechanisms for how the full range of perspectives is included using the decision-making model and structures that the ICB employs.

• ICBs will also be expected to comply with good governance practices for example on board size, to allow appropriate decision making to take place.

Key considerations

Every ICS needs to determine what is right for its area. But we would suggest there are some key considerations in developing these proposals. Our starting point is that before determining the membership of the ICB, there must be a clear understanding of the different components of the ICS and how they are intended to work together. This ‘whole system’ approach to governance is needed to ensure that different players are involved in the right way.

• ICS principles – most ICSs are operating to a set of principles; these should be reviewed in light of the principles set out in the ICS design framework. ICSs need to consider what these principles, such as subsidiarity and collaboration, really mean in practice, and how they will shape the governance structures being developed.

• ICS governance principles – we would urge all ICSs to agree on a set of governance principles to complement the ICS principles and enable the full range of perspectives to inform decision-making. Concepts such as clear accountability, streamlining, lack of duplication, agility and additive value of assurance are key in helping to think through the governance arrangements that need to be put into place.

• System working – ICSs need to have a clear proposal for the roles to be played by different parts of the system in the statutory ICS. What will be the tasks given to place, to providers and to provider collaboratives to both transform and deliver services? What will the board delegate to the executive, the CEO, the ICS executive and system partners, in order to effectively run the day-to-day operation of the system? How will the annual planning cycle work in the ICS, so that strategies and plans are developed in a collaborative and inclusive way? How will the system assurance framework operate and what role will ICB committees play? What about region? It will not be possible to agree on every last detail, but well-thought-through answers to these questions developed with system partners is essential before any strong view is formed about specific issues such as the membership of the ICB.

• Purpose and role – in line with the oft-quoted ‘form follows function’, there needs to be a clear understanding of the role of the ICB and the role of members of a unitary board in formulating system strategy, holding to account and promoting healthy cultures, all in the interests of the ICB. It is equally important to recognise what an ICB, as a board with responsibilities for the health of millions of people and billions of pounds of public money, does not do, and the processes that need to be in place to ensure that any proposals brought to the board have been developed in line with the ICS principles.

At GGI we favour lean governance for ICSs. It is important to clearly distinguish between governance and management, as not everything that needs to be managed needs formal governance.

Key principles of subsidiarity and collaboration must be honoured in order for ICSs to fulfil their purpose and improve outcomes for their local populations.

It is also normally easier to add additional members at a later stage, rather than starting with a larger group and seeking to reduce its size once it’s found to be ineffective. So we propose that ICBs are constituted at a minimal size unless a clear case for additional membership can be proposed.

As such, when ICSs are considering proposing additional members for the ICB, we would urge them to consider these questions:

• How will the additional membership support the ICB to carry out its role and achieve its purpose?

• Can the purpose of additional membership be achieved in any other way, such as a more inclusive executive function, clearer delegation or robust planning and engagement processes?

• How does the proposal align and balance with membership of other parts of the system, such as the integrated care partnership, provider collaboratives and place-based partnerships?

• What are the implications for conflicts of interest and, in relation to partner members, perceptions that members are representing an organisation or interest rather than bringing a perspective from a sector?

GGI has led the national conversation on integration and we have already worked with a number of ICSs across England. No one is better placed to guide you on the important journey to integrated care. Please call us on 07732 681120 or email advice@good-governance.org.uk.