Strengthening system governance

by Lisa Robertson

20 August 2018

Throughout August we are taking the opportunity to focus on some key areas of the HFMA’s policy and technical work and remind members about some of the outputs that might be useful. Each week we are highlighting a different topic. This week, the focus is on system governance.

System working is here to stay and will be a key part of the new 10-year plan – vital to its success is strong system governance. The move to collaboration over competition comes with significant governance challenges but also an opportunity for tangible transformation to a place-based and patient centred health service.

System working is being developed in a complex, and often confusing, environment. Refreshing NHS plans for 2018/19 reinforces the move to system working in ‘planning and managing system wide efforts to improve services’ and aims to clarify the role of the different system mechanisms including sustainability and transformation partnerships (STPs), accountable care systems (ACSs) and integrated care systems (ICSs)

Building on findings from the November 2017 HFMA NHS financial temperature checkwhich found 60% of trust finance directors and 42% of clinical commissioning group chief finance officers were concerned about STP governance arrangements – the HFMA STP governance survey helped build a comprehensive picture of developing governance arrangements.

The survey found mixed experiences, being early days for many. When asked what aspects are working well, it is pleasing to note comments reflected improvement in collaboration and relationships. Examples highlighted the strength in bringing together clinical leaders, finance leaders and general managers. However, concerns remained, particularly over the lack of clarity and transparency of the vision and decision-making, lack of agreed STP-wide resources and lack of accountability to and from individual organisations.

Existing structures can make it difficult to work in partnership. The need to develop a system-wide approach, while retaining the existing architecture of separate organisations has led in some cases to a lack of clear accountability for delivery and decision-making. Some areas have turned to structural change, explored in the HFMA’s November 2017 briefing, Combining NHS bodies – a practical checklist for mergers and acquisitions. Others are using different methods to work around the issue such as changing payment practices and contracting methods.

In all cases, the key to success is good relationships and trust. At the recent HFMA Convergence event, we heard some great examples of making system level working a reality.  The overriding theme was the importance of relationships and collaboration, both across organisations and between clinical and non-clinical staff.

Everyone has an important role to play in ensuring the opportunity for transformation is taken by effective system working. One such role is that of non-executive directors in overseeing the whole, providing robust challenge and support. The HFMA’s October 2017 briefing, Sustainability and transformation partnerships: developing robust governance arrangements, includes a diagnostic tool to underpin board, governing body or audit committee discussions.

Over the coming months HFMA will continue to provide opportunities to share experiences and work through next steps together. Watch out for:

  • a system governance series of short briefings on aligning resources, decision-making and risk sharing
  • the launch of a corporate governance map with links to essential governance tools and guidance
  • the Healthcare Costing for Value Institute 2018 international symposium, in October, with a focus on driving value across the system
  • a meeting in early autumn to see what the appetite is for an HFMA system finance lead group and what it could focus on. This will be complementary to the existing NHS England finance group, facilitating leads to get together to share experiences and help shape the HFMA’s work in this area. 

If you are interested in either sharing your experiences to feed into our upcoming system governance series or join the initial meeting of the system special interest group, I would love to hear from you at