Integrated care systems – three priorities for governors and NEDs

Feeling sidelined or failing to fully engage with the planning for integrated care are the wrong moves; now is the time to consider how integrated care systems are going to work, focusing on the primacy of place.

“For now the winter is past, the rain is over and gone. The flowers appear on the earth; the time of singing has come, and the voice of the turtle dove is heard in our land.”

This quote, from the Song of Solomon, appears in the Old Testament in the Bible. A harbinger of spring, renewal and new growth; a metaphor, perhaps, for what is coming to health and social care in the form of legislation to embed integrated care systems. In that context, it’s interesting to ponder over who will be the voice of the turtle dove.

It’s notable that within the thousands of words used to describe ICSs in the white paper and other guidance, you will search in vain for the word ‘governor’ and will trip over ‘non-executive director’ only occasionally. And yet these offices will retain statutory duties in the new world. They have no formal allegiance to a (currently) non-statutory local body that is slowly but surely, like a python swallowing a pig, taking control of their destiny.

That said, it is difficult to be very critical of aims to break down barriers and deliver better outcomes in close collaboration with other organisations. The triple aim of better health and wellbeing for everyone, better quality of health services for all and the sustainable use of NHS resources is beyond admirable but it evades the complex reality.

Collaboration must not be half-hearted

In 1946, Aneurin Bevan said: “No legislation, however wisely conceived and however efficiently embodied in an Act of Parliament, can ever give the public a great health service unless the people who administer it want to do it and are enthusiastic in doing it.” Willingness to collaborate cannot be half-hearted.

It is incumbent on all parties to recognise this and to respect the challenges that each has to face. The accountability of a local authority differs to that of an NHS trust but both have equivalent authority and being willing to delegate some of it will need everyone to take a deep, organisational breath.

The white paper suggests that ICSs will have a double-headed governance arrangement that preserves the purchaser provider split. We’ll see if that survives the parliamentary process. But the governance arrangement for the ICS NHS body is to establish a unitary board with a chair, CEO, accounting officer and representatives from trusts, GPs and local authorities as well as others to be determined locally. The board is also expected to take appropriate clinical advice.

Remember, this is in addition to other governance arrangements and responsibilities and while there is no mention of wider public participation when major decisions are to be taken it is inconceivable that this will be stood down as a fundamental requirement. There should be loud protest howls if this turns out to be the case.

Providers remain influential

Provider non-executive directors and, even more, governors of foundation trusts may feel sidelined but they must know that pushing at a tidal wave and telling it to back off will not work. No, we must all find ways of working with the system. GGI recently published some guidance on working together which included a section on working within the system.

Delivery of care to patients and the way it is planned and paid for is changing. Non-executive directors and governors must understand the changes to funding from activity-based payments to blended funding based on local population needs. Thinking through the implications – especially as there is likely to be a single pot of money for each system with the ICS the body for financial delivery while accountability remains with trusts – is a key priority.

Providers will become part of a local collaborative while remaining accountable for their current range of formal and statutory responsibilities. Does this mark the end of any provider influence? We think not. Foundation trusts’ ‘ownership’ of their capital may end and their plans become part of system-wide arrangements. In a gesture towards diluting the duty laid on FT directors to promote the success of their organisation, FTs will be permitted to form joint committees with other providers and participants and be authorised to deal with delegated decisions. But in a planned economy, providers remain central to both local and specialised commissioning as well as delivering services.

The voice of the turtle dove

More particularly, if change is coming working out how to run with it will be more positive than looking for ways to subvert it. Thinking needs to move away from the institution itself to the institution’s role in delivery across the system. In other words, it’s about becoming much more outcome-focused and seizing the opportunity to develop preventative health initiatives and deepening links into the community, primary care and education.

Reviewing how the plans are put into practice and to the quality aspired to forms the basis of accountability and assurance. Delivering across a local geography rather than just a part of it should provoke thinking about the contribution each constituent could and should be making. ICSs should be encouraged to talk openly and frankly to the people they serve by establishing engagement forums as well as undertaking formal consultations.

No trust offers every service or pathway and so there should be improvements that all patients and service users benefit from as much as this being true of services any single trust makes more readily available to others.

But for the future, the primacy of place is the voice of the turtle dove.

Illuminations

• Willingness to collaborate cannot be half-hearted - it is incumbent on all parties to recognise this and to respect the challenges that each has to face.
• Pushing at a tidal wave will not work – finding ways to work within systems is more positive than resisting change or looking for ways to subvert it.
• Primacy of place is the theme for the here and now – delivering together across a geography should provoke thinking about the contribution constituent organisations should be making.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk.

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