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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

¹ Corporate Governance: Improvement and Trust in Local Public Services, Audit Commission, 2003

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.