Whatever the legal functions and duties of integrated care systems and their associated partnerships and collaborations, it is inevitable that leading them successfully will involve governance between organisations.
There is no recent, strong evidence to suggest that there is 'a right way' to ensure good governance between organisations. What evidence there is goes back to research carried out by the Good Governance Institute in 2011. This research identified the quality of relationships as crucial in determining the delivery of good governance between organisations. There is more to do to put flesh on the bones of the proposals in the white paper, in practical terms, but what has been published implies that strong relationships within and between organisations will be central to the way in which the NHS in England operates, and delivers for patients, in future.
Intuitively we know the importance of good relationships in making things work well, both within and across organisations. New ventures or partnerships are often based on existing strong relationships. But it would be a mistake to imagine that good relationships will always persist or will survive a change of personnel. Our life experience teaches us all otherwise and it would be a high-risk strategy to rely entirely on the persistence of good relationships to keep on delivering indefinitely.
But equally we cannot depend entirely on structural approaches to deliver good outcomes from system working.
Specialist advisor (Governance)
But equally we cannot depend entirely on structural approaches to deliver good outcomes from system working. NHS trust and foundation trust boards that have failed and those that have thrived have had the same or very similar structures, work to the same rules and use the same processes. Rules, processes, and procedures do not produce boards at trust level that always deliver good outcomes and they will not automatically produce good outcomes at a system level.
If relationships change over time, and if structural approaches cannot be relied upon how do we build collective and collaborative leadership that functions well and continues to do so over time? Once again there are lessons from successful boards. Back in 2002 Jeffrey Sonnenfeld, in his article 'What makes great boards great' identified the importance of developing a virtuous cycle of respect, trust, and candour: "Team members develop mutual respect; because they respect one another, they develop trust; because they trust one another, they share difficult information; because they all have the same, reasonably complete information, they can challenge one another's conclusions coherently; because a spirited give-and-take becomes the norm, they learn to adjust their own interpretations in response to intelligent questions."
Although the article is nearly 20 years old it has yet to be bettered in its analysis of what it takes to provide effective leadership and direction.
Specialist advisor (Governance)
Although the article is nearly 20 years old it has yet to be bettered in its analysis of what it takes to provide effective leadership and direction, not only to single organisations, but also to collaboratives and partnerships. Ahead of a further set of far reaching legislative changes for the NHS, it is timely therefore to revisit it.
To borrow from Sonnenfeld, maintaining good governance between organisations will depend on creating the virtuous cycle of respect, trust, and candour. This will depend on system leaders creating the right climate by building trust. The provision of full, honest, and transparent information is key to building trust. All the key players and decision makers need to know that they are receiving the information that is difficult to hear or share as well as the good news. Cognitive bias and the formation factions need to be discouraged and system leaders also need to be wary of undue influence by strong personalities, including their own.
However to make Sonnenfeld's virtuous cycle work there needs to be the same culture of constructive challenge that is commonplace within successful NHS trust boards. This isn't just about challenging information and assumptions but also perspectives and opinions. As Sonnenfeld stated: "Respect and trust do not imply endless affability or absence of disagreement. Rather, they imply bonds among board members that are strong enough to withstand clashing viewpoints and challenging questions."
In the NHS, where compliance is often the norm, system leadership teams will need to build a culture where dissent is not only welcomed but is regarded as an obligation.
Specialist advisor (Governance)
In the NHS, where compliance is often the norm, system leadership teams will need to build a culture where dissent is not only welcomed but is regarded as an obligation and where everything is up for constructive challenge and debate will be a challenge in itself. But it should be remembered that it is not only in the NHS where dissent is sometimes taken as disloyalty. Sonnenfeld observed that: "Directors are, almost without exception, intelligent, accomplished, and comfortable with power. But if you put them into a group that discourages dissent, they nearly always start to conform. The ones that don't often self-select out."
The task for systems is to encourage its members to act as problem seekers who look for the difficult truths, challenge one another and where necessary stand their ground in the face of a contrary majority view. This has to be part and parcel of the culture of systems and something that system leaders demonstrate and model in their work if we are to deliver good governance within systems – and ultimately improved outcomes for the public.
What is true of systems remains true for NHS trust and foundation trust boards where fostering trust is vital and where challenge and problem seeking are an intrinsic part of the board's work. For foundation trusts the same applies to councils of governors. Boards have a responsibility to foster trusting relationships with their councils of governors and councils have a duty to reciprocate in kind. Councils can help their boards in asking about the work the board does to ensure robust challenge and to seek out and tackle problems as and when they arise. Councils should ask their boards to be informed of the board's approach to fostering trust and how they as a council can contribute.
This blog has been updated following its first publication on 28 April 2021.
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