Comment / The implications of integrated care

NEDs do not seem to have played much of a part in STPs. Yet at a time when the NHS is facing arguably the biggest challenges in its 70-year history, the need for NEDs to understand these changes and what they mean for their own role and responsibilities has never been greater. So it was good to share my thoughts on these issues at a recent HFMA network event for chairs, NEDs and lay members, drawing on my experience as a NED of an acute and community trust over the last three years as well as my role as a health and social care policy expert.

My overall message was to ‘think system’. The challenges facing the NHS – arising from changing needs, rising demand, money and workforce – are now so great that organisations cannot meet them on their own without collaboration across organisational boundaries. Accountable care is really about integrated care – how different parts of the NHS work together, and with local authority and third sector partners, to better coordinate care for individuals and improve the health of their local populations.

The language used is far less important than each local system having a clear vision and plan. But as yet STPs and most examples of integrated care are not legal vehicles in their own right and the fundamental responsibilities and accountabilities of trust boards remain entirely unchanged. The regulation of separate organisations has yet to catch up with expectations of system working, although the Care Quality Commission’s programme of local system reviews is a welcome step in the right direction.

The central purpose of NEDs remains that of ensuring effective governance oversight of how effectively their own organisation is ensuring the quality and safety of care, meeting constitutional targets and achieving financial balance. Triangulating these expectations is massively challenging as the King’s Fund’s own quarterly monitoring reports of NHS pressures continues to show. NEDs are expected to seek assurance from executive directors, whose ability to provide that assurance has never been tougher.

This represents a massive stress test of relationships within boards between NEDs and their executive colleagues. Getting the right balance between support and challenge calls for sound and mature judgement. Boards that can withstand these pressures and perform well are likely to be those that have invested time in nurturing relationships through board development programmes.

As different forms of integrated care partnerships evolve, all boards now need to consider how they develop a dual focus on the performance of their local system as well as that of their own organisation. It remains unclear how far this can be achieved within current governance responsibilities without legislative change. The Health and Social Care Act 2012 places a general duty on boards, and on directors individually ‘to act with a view to promoting the success of the corporation so as to maximise the benefits for the members of the corporation as a whole and for the public’ (schedule 7 para 18a of the National Health Service Act 2006, as amended by section 152 of the Health and Social Care Act 2012).

In the new world of accountable care, the ‘benefits for the corporation’ and ‘for the public’ may not be one and the same. This is one of many ambiguities that boards will confront in trying to be collaborative within a legal framework that was designed with a different purpose in mind.

There are no easy or immediate answers. In the meantime there is no doubt that as collaborative system working gathers pace, NEDs should spend more time in developing relationships and networks with other parts of their local system as well within their own trust.

Former colleague Jocelyn Cornwall’s letter to a friend offers sage advice to NEDs that is even more relevant today. Recent research from Birmingham University and the Nuffield Trust highlights the value of a ‘restless board’ that seeks constantly to compare itself with others and seeks ways to improve.

And a clear lesson from efforts to achieve integrated care over the last 40 years is how much progress is driven by building trust and collaborative relationships rather than organisational structures and governance. That is as true for NEDs as it is for the NHS as a whole.