Integrated top to bottom

The way services and professionals are “governed” goes to the
heart of professional practice and organisational effectiveness.
Successive reorganisations in the NHS and local government, as well
as the changes ushered in by clinical governance, care management
and the General Social Care Council, will all affect
governance.

The dramatic shift towards joint working and integrated structures
has added a further factor – that of “joint governance”.

The first difficulty is pinning down the concept of governance – a
word that has been loosely used in the past. The recent Audit
Commission report on corporate governance, for example, defines the
term as: “The framework of accountability to users, stakeholders
and the wider community, within which organisations take decisions,
and lead and control their functions, to achieve their
objectives.”¹ Put simply, governance is about ensuring
that decisions are taken in a clear and appropriate way.

The levels of governance are:

• Individual level governance, as with care management.
• Corporate level, as with procedural rules.
• Organising level, as in the use of markets, hierarchies and
  networks as co-ordinating mechanisms.
• State level governance, as in the balance of power between the
  centre and localities.

Since it is only in the past 10 years or so that joint forums of
one sort or another have really taken off, the debate on joint
corporate governance has a limited history. The old Joint
Consultative Committees created in the 1970s were widely regarded
as ineffective and had all but disappeared by the early 1990s, and
the decision by the then Conservative government to end local
authority representation on health authorities seemed to close the
debate. However, the recent growth of new bodies such as care
trusts, children’s trusts and the myriad of joint forums created in
the wake of section 31 agreements has inevitably thrust the issue
back into prominence.

Joint governance is not without its problems. Part of this relates
to structure and representation – the balance of membership is
often seen as a reflection of the relative worth and status of the
parties, and can therefore engender strong feelings. Some of the
negative reaction to the notion of care trusts, for example, has
come from local authority interests who are worried that shared
governance might be a cover for an NHS takeover. Where a local
authority elected member is a member of the board of a care trust,
accountability is to the care trust board, not back to the council,
and this may leave such councillors with dual – and conflicting –
routes of accountability. As children’s trusts emerge, the
situation may be reversed, with NHS members concerned about their
position on the local authority-led boards.

However, it is not just a question of structure, but also one of
process. The traditional ways in which local government and the NHS
have conducted their business at corporate level have differed in
some important respects. There may be differences in the ways
papers are written, the manner in which members (or non-executive
directors in the case of the NHS) are briefed by officers, the
extent of involvement prior to board meetings, and the ways in
which speech is structured and business is discussed. Most
obviously, politicians will expect to talk the language of
politics, while non-executive directors will expect to demonstrate
specific expertise of a technical or community nature.

The danger is that if the nettle of shared governance is not
grasped, then representatives of the various parties may take away
their bat and ball and simply leave, or downgrade the role of the
partnership forum. One way of addressing this is to have clear and
unambiguous partnership agreements, setting out the terms of
business and the rules of engagement, including how to address the
potential breakdown of relationships. However, no matter how
legally and procedurally watertight such an agreement might be, it
can never compensate for good relationships – good governance is
built on the back of secure and trusting relationships, rather than
the other way round.

About 180 delegates participated at a recent national event
organised by the Integrated Care Network to explore corporate
governance. In a paper prepared for the event by the Health
Services Management Centre at the University of
Birmingham,² it is suggested that corporate boards are
best viewed as symbolic rather than instrumental. With the
instrumental model, the work of boards is seen as rooted in
decision-making, especially of a strategic nature, and members are
appointed who have the skills to assist in this process. But in the
symbolic model, the purpose is more one of portraying loyalty,
solidarity and organisational coherence – a symbol of a shared
approach and one that also sets the context for partnership.

This should not necessarily be seen as a bad thing. It is
inevitable that ideas will be developed and decisions made in a
range of settings other than the corporate board, whether it be
smoke-filled rooms or user/carer forums. What is important is that
the papers, proposals and developments that do find their way to
board level have been the subject of proper consultation and
reflection. Moreover, the model can only be effective where all
participants share the same understanding of the symbolic purpose.
The evidence suggests that three stakeholders might not share this
understanding: GPs (who can be quite individualistic), users and
carers (who like to make their point through a personal narrative
that might be considered inappropriate for board level meetings)
and politicians (who may be prone to speak and behave
politically!).

Joint governance presents a challenge to the government’s
commitment to “new localism”. In principle this may involve
strengthening and reforming local government, but it is also likely
that responsibilities for such matters as health and police could
be passed to new community agencies. The difficulty here is that
within a given local area there may be separate bodies, each with
responsibility for such diverse services as adult community
services, children’s services, acute care, police and others.
Effective shared governance across a locality must leave room for a
whole systems vision. Partnership working is all about recognising
mutual inter-dependence – the ability of one organisation to
achieve its goals is invariably dependent upon what goes on in
another organisation, as in the issue of effective hospital
discharge. Somewhere in the system there needs to be an
over-arching body of governance that can take a view on how the
bits of the jigsaw do – or do not – fit together.

Governance is a very contemporary term, one that has emerged in
less than a decade from virtual obscurity. The additional
complication of joint governance is one that will take time and
effort to address, and in many respects the debate is only just
beginning. 

Bob Hudson is professor of partnership studies at the
Centre for Health Services Management, University of Birmingham and
an associate of the ICN. Shane Giles is director of the ICN, and
Alix Crawford is network manager of the ICN.

References

²
Integrated Working and Governance: A Discussion
Paper, available to download in full from the ICN
website

Further information

To find out more about the ICN see
www.integratedcarenetwork.gov.uk
To e-mail, go to “contact us” on the website, or call Shane
Giles, director, 0113 254 3804. Alix Crawford, network manager, 020
7972 4375, Claire Clague, office manager, 0113 254 3855.
The next ICN national meeting will take place on 22 January in
London and is entitled “The Nuts and Bolts of Integration”. To book
a place go to the website.