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• The Development of Integrated Governance (opens new window)

During a series of short, key-note addresses at the workshop chief medical officer Sir Liam Donaldson picked up the challenge of integration but reflected that it was new to the NHS, as well as to health care systems around the world.

In setting out his vision for the work of a board in an integrated governance environment, he was clear that it would not only improve governance but would also be in patients' interests by better assuring the quality of their care.

Bill Moyes, the foundation trust regulator, was concerned that the governance systems of many aspirant foundation trusts did not reflect the tougher environment in which they would be working. (His reference to the present system of strategic health authority support as 'sugar-daddies' for NHS trusts caused some merriment!). His overall view was that whilst clinical governance was generally satisfactory, financial discipline and risk management needed higher standards of control. He welcomed any effort to reinforce board responsibility.

His view was reinforced by Healthcare Commission chairman Sir Ian Kennedy, who said that boards needed to improve their internal supervision mechanisms.

They needed to increase corporacy with better joint acceptance of accountability.

He saw compliance with the new Core Standards as a basic licence to operate since the standards incorporated some of the fundamental requirements for addressing patient needs and expectations. He was able to reassure the audience that the Healthcare Commission was working to minimise any overlap between its own assessment of the NHS and those carried out by other organisations.

Sir Ian concluded that integrated governance would ensure that boards could add lasting value to their organisations.

Sir William Wells, chairman of the NHS Appointments Commission set out the importance of a coherent governance framework for boards. He agreed that objectives with properly-assessed risks were an essential starting point but they needed to be kept alive with regular board monitoring.

He commended the Assurance Framework, produced by the Department of Health, for providing a sound framework in which the objectives and their risks could be managed. The framework also integrated the various governance strands in a way which was simple and accessible. However, he was critical of the complexity of the Controls Assurance system, which he labelled as a tick-box exercise with little board involvement.

NHS finance director Richard Douglas went even further. Citing Controls Assurance as a 'monster' and the view that it was one of the biggest bureaucratic burdens on the NHS, he explained that he had set up a group to review it.

Wearing his 'bureaucracy-busting' hat, he was keen that integrated governance should be simple and not itself develop into another complex regime.

NHS chief executive Sir Nigel Crisp reviewed the substantial progress made by the NHS in recent years to meet the expectations of patients. Nevertheless, he pointed out that the planned decrease in central control from the department would put boards on their mettle to develop strong and integrated governance systems to take on the greater responsibilities devolved to them.

The NHS would need to change in order to face the major challenges, such as chronic disease management, which confronted it. Boards should not be risk averse but, with strong systems of risk management, should feel confident to innovate and make changes. In conclusion, he commended boards for their work so far but suggested that they would need to do even better.

The workshop was a spirited event led by Nigel Edwards of the NHS Confederation, and delegates took the opportunity to offer wide-ranging views on current board systems. Many felt that the silos, which characterise current governance, were reinforced by various external performance management and inspection regimes. These would need to be addressed before integration could be achieved.

All were clear that board systems needed to be simplified, although there was concern that a directive 'one-size-fits-all' approach would not be helpful. Some felt that integrated governance could be guided by patient care pathways, others that the strategic health authority had a role to play.

There was some misunderstanding that the BAPs themselves would be too directive, but it was explained that it would be for boards to develop their own set. The BAP approach was primarily a way of thinking.

There was consensus from delegates that training for whole boards, that is executives and non-executives together, would be essential. Integrated governance would place a premium on board corporacy and team working, requiring good information and constructive challenging.

In thanking delegates and summing up, Peter Bareau, chair of Surrey and Sussex Strategic Health Authority, who chaired the afternoon session, concluded that there had been a clear mandate for integrated governance. The authors of the paper would now have the guidance needed to take forward the concept.