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New governance models needed as we move towards greater integration

The Good Governance Institute’s chief executive, Andrew Corbett-Nolan, argues that as we move towards greater integration and collaboration, new models of effective governance between organisations need to rapidly emerge.

The NHS is facing an existential crisis and it is well recognised that neither the funding nor organisational models are sustainable in the future. No longer is it the isolated position of technical process and structures underpinning a policy framework based on individual organisations. In the context of an ageing population, an increasing prevalence of long-term medical conditions, the rising cost of care and a predicted £30bn funding gap by 2020, without taking radical whole-system transformational action, the future of an already broken system looks bleak. 

Sir William Wells, former chair of the NHS Appointments’ Commission, has described the NHS as a system that is “bordering on complacency” and one that “successive governments continue to bail out with just enough money to starve off a crisis yet not enough to make any major change”. Whilst Simon Stevens, chief executive at NHS England, has warned that if efficiency savings do not materialise, “the result will be some combination of worse services, fewer staff, deficits, and restrictions on new treatments”. Already, the King’s Fund suggests that although “there are significant opportunities for the NHS to deliver better value care…these cannot be achieved at the pace or scale needed to deliver £22bn of efficiency savings by 2020-21”. 

What does this mean for regulators and compliance? 

The CQC, in its paper ‘The state of health care and adult social care in England 2015-16’, reports that it is increasingly concerned about the sustainability of quality. In 2015-16 almost half of services re-inspected following a rating of ‘requires improvement’ failed to improve the quality of care they delivered. In 8% of cases, the quality of services actually deteriorated. Likewise, NHS England’s annual assessment of CCGs revealed that out of 209, 91 were rated as ‘requires improvement’ and 26 as ‘inadequate’. 

Professor Charles Swainson, EHealth clinical lead for the Scottish government, and Alan Milburn, former health secretary, have recently argued that, in order to improve quality and realise efficiency targets, there is a pressing need to “find a long-term funding settlement for the health and social care sector”. 

NHS England and NHS Improvement (NHSI) have set out, in a seven-point plan, steps that will be taken to ‘reset’ NHS finances and address the growing provider deficit, including new intervention regimes and a cap on interim spending. As a result, nine CCGs and now eight trusts have been placed into financial special measures. Other trusts will only be able to access money from a £1.8bn sustainability and transformation fund if they sign up to a financial control total agreed with NHSI. 

Although the ‘reset’ was generally well received, some have voiced concerns that it could lead to staffing cuts and the de-commissioning of services. Nigel Edwards, CEO at the Nuffield Trust, fears that “in order for hospitals to virtually eradicate their debts, as NHSI and NHS England want, the next steps could be a series of brutal service reductions and bed closures – which will shock an unprepared public”. 

What is clear is that as the focus shifts towards balancing the books, regulators will need to work increasingly closely with providers to ensure that services, staff and patients are not neglected. This will require traditional provider-regulator roles to be revised, with continued effort to reframe the relationship as one based on mutual trust and support, rather than solely on compliance. 

What about the future? 

Stevens has argued that STPs are a way of confronting “the big local choices needed to improve health and care across England over the next five years”. It is too early to gauge whether the plans and the new models of care they envisage will be effective, but already they present some wicked problems in terms of regulation and compliance. 

In the new world, services traditionally delivered by one organisation will be delivered across groups of organisations. Regulators will need to adapt their assessment frameworks to reflect this. 

David Behan, CEO at the CQC, has already spoken of increasingly “mixing the skills of our inspectors”, to ensure that inspections are appropriately representative. This echoes the thoughts of Stephen Dorrell, chair of NHS Confederation, that “it is very important that the regulatory process doesn’t stand in the way of those [necessary] changes, but actually they deliver effective monitoring of the standards being delivered”. 

The way that individual organisations interact and hold each other to account for poor performance will need further attention. Failed efforts to integrate services in the past have resulted from a lack of robust formal governance mechanisms underpinning partnerships as opposed to a lack of willing or effort. 

We would expect to see organisations develop a shared understanding of clinical risks, comprehensive risk-sharing arrangements, and organisational objectives aligned to a meaningful board assurance framework, reinforced through strong leadership. 

Informing all this must be quality information. Professor Derek Bell, president of the Royal College of Physicians of Edinburgh, recently made the point that “the NHS is data rich but information poor…particularly in relation to the presentation of information to NHS boards”. The board fulfils an important oversight function, but in order to appropriately challenge, hold management to account and take decisions, they must be supported by meaningful and ‘live’ data. 

Ultimately, integration and collaboration is here to stay. The challenge for governance has never been greater and new models of effective governance between organisations need to rapidly emerge.

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