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Navigating governance and moving beyond a focus on structures

Overcoming barriers to delivery
Barriers to delivery



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.

man running

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.
man breaking through

“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.


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