Provider boards need to ensure new partnerships and associated programmes of work are embedded within their governance arrangements, to maintain oversight of activities and progress. At the same time, partners will need to establish structures and processes to enable effective planning, development, and delivery of work programme(s).
Leaders engaged through this programme regularly talked about the importance of good governance. Ensuring good governance – that the boards of the organisations involved exert appropriate control over the partnership, the activities of which they retain legal liability for – and setting up structures and processes to manage a partnership, are linked but importantly distinct activities. Being clear about this can help to navigate the space.
Each organisational player involved in integrated working will have its own organisational governance (that is, system of leadership and internal control), and unless partners have formally merged to create a new organisation, oversight of place-based integrated structures should be undertaken through the existing governance structures of each organisation.
Partnership working to achieve specific outcomes is usually a question of having effective programme or project management in place, including clinical oversight – so the leadership, control, and performance monitoring of most partnerships’ activities will happen through programme management.
Governance of the partnership requires agreement between partner boards regarding the degree of reference back to the boards that is needed to make decisions and to escalate to those boards any areas of risk to the partnership or its activities, and clarity about the extent of delegated authority that executive leaders running the partnership’s operational activities have from their board.
Below the level of the partners’ boards, partnership management structures will be set up to plan and run the programme(s) of work.
Leaders involved in partnership working note the draw it can make on their capacity, and that complexity can creep in, with a focus on setting up structures and processes rather than progressing the aims of the partnership programme. Embedding reporting/reference to provider boards in their existing governance structures should minimise any requirement for additional structures to enable board governance of the partnerships’ activities. The management structures set up below should be proportionate to the work being undertaken and need not be overly complex. All arrangements should be subject to review and evolution as required: if things are getting complicated, change them. Using the expertise of governance professionals within the partner organisations at the outset should help.
What is the reality? The challenges being felt by local systems
- Existing organisational governance structures can be perceived to overlap with place-level management structures and processes designed to drive specific change programmes.
- Staff are being asked to join or service an increasing number of forums (both organisational and place-focused), when capacity is under pressure.
- Places are bringing together a complex web of services, delivered by a distributed network of staff, so being clear on oversight arrangements and how risks are managed and delivery monitored is not straightforward.
- Disagreement regarding where clinical responsibility sits can be seen as a negative risk currency, impeding change.
- Debates about optimal geographies to focus on can cause misunderstanding and slow delivery.
- There is a risk that systems and places confuse management structures with the need for oversight from partner organisations’ boards/leadership teams and set about creating new structures without focus on the outcomes.
- Multi-agency partnership oversight groups are sometimes constituted so that multiple functions of partner organisations are represented. This can lead to groups of 20 or more participants, where responsibility becomes diluted, and decision-making is slowed. Be clear who needs to be in the room and ensure they have authority to take decisions.
How are systems overcoming the barriers?
Some leaders reflected that they are managing to effectively navigate a changing landscape in recent years and are in a strong position to progress delivery. Key learnings for success include:
- Clear joint decision-making arrangements, a set of agreed strategic priorities shared by partners, and dedicated leadership resource.
- A small number of priority work programme, with specific deliverables linked to outcomes.
- A realistic investment in workforce and transformation.
- Executive leads for each work programme, supported by multi-agency thematic leadership groups to drive delivery.
“The examples of integration that work can talk about integration of service users and clinicians, or integration of the population with services, or services with services. There is a risk that in navigating changing governance arrangements, we orientate around structures, that we integrate ourselves but not our population.”
Chief executive, Community and Mental Health Trust
For more details, a recent NHS Providers report on place-based partnerships explored how partners in a small number of places are coming together to take decisions and drive forward delivery.
Shared learnings on practical tools and approaches
The following learnings have been drawn together based on the engagement and input into this programme of work.
- Keep the programme management and clinical governance focused on the practical changes and work to be achieved, with the right people in the group who will be able to move towards that goal. This may sit within existing forums at place.
- The programme management team is responsible for delivering the outcomes, the organisational partner boards remain accountable for the existence of the partnership/its objectives (bear in mind the principle of the inside out approach – set up governance and management structures based on outcomes, rather than process).
- Governance arrangements need to balance oversight and effectiveness. Partner organisations need to be engaged, but there are risks from discussions with too many people in the room to be effective. Reporting to partners can be risk-based and proportionate – escalating where high-risk, or high-value decisions are being taken to ensure robust oversight.
- Where decisions are taken through delegation from partner organisation boards, representatives should be clear about the limits of their decision-making authority, reporting requirements back to their boards. Partner boards should be sighted on any intention to change strategic direction in terms of the aims of the partnership.
- Ensure governance arrangements are designed into the change programme from the beginning. As part of the design and mobilisation phases, use governance professionals’ expertise to work through and agree accountabilities and responsibilities with partners.
- Be prepared to tweak and iterate governance and programme management arrangements as programmes move through different phases.
- Simpler management arrangements tend to be easier for teams to work in, with greater clarity on reporting providing more effective oversight.
- Where possible, embed governance into existing structures, rather than adding to them.
We hope that this publication will not be the end of the programme, but the beginning of a conversation. A series of events will be available to attend to explore the themes in greater detail and share experiences.
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