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The governance of collaboration

by Sarah Dowbekin

13 June 2019


Working together is key to delivering assurance across increasingly integrated systems

Over recent years we have seen an increase in public sector organisations working in partnership for the benefit of the populations they serve. By working together organisations are able to achieve more than by working in isolation. And with the NHS long-term plan putting an increased focus on integrated care systems, working in collaboration continues to be the clear direction of travel.

Integration is clearly the agreed way forward and, in the absence of formal restructuring, this means working in partnership. This also means creating governance arrangements that enable organisations to focus both on their organisational objective and those of the partnership. Although difficult, this is achievable as seen by the models emerging. This principle of partnership – and the governance arrangements needed to enable it – are demonstrated in a number of case studies in a new briefing from HFMA – Case studies from the HFMA governance award 2018.

One example is the Northern Care Alliance NHS Group, formed with the ambition of enabling best practice care found in successful NHS organisations to be extended to those hospitals struggling to meet standards. It achieves this by deploying a standard operating model at scale to drive improvements, demonstrating that when integration works it increases engagement and encourages the sharing of best practice.

The Northern Care Alliance Group brought together the five local hospitals of two trusts to form four care organisations (COs). These COs are not only responsible for providing healthcare services to local communities, but also play a much broader role in each locality including closer working with local authorities to improve care.

This fundamentally changed the structure of the organisations. The Northern Care Alliance is governed by a committees in common (CiC), where both NHS trusts have devolved it decision making. For each of the four COs, the leadership team of directors have clear accountability and authority to govern their CO, overseen by a group assurance structure including the group board, group assurance and risk committee, and the group audit committee. 

Creating a group model like this across organisational boundaries required a review of governance arrangements to transform how assurance is provided. The organisational form must enable robust risk management and integrated assurance to be delivered. And internal audit is a big part of this.

For the Northern Care Alliance, group internal audit provider, MIAA, played a key role in this transformation journey. MIAA delivers audit, assurance and advisory services to the public sector and, in particular the NHS. In a group model, the internal audit approach must replicate the principles of the organisational form by encouraging the sharing of good practice, meeting the requirements of each organisational level and asserting consistent focus upon assurance and risk. Just providing more assurance is not the answer.

Internal audit working collectively with non-executive directors and executive directors is the key to implementing a robust assurance model. Clear communication through a variety of means, including workshops and committee meetings, ensures continued and ongoing engagement with the organisation’s transformation journey.

Developing an integrated assurance regime is an iterative process. A key dependency is organisational maturity in terms of defined structures and autonomy. Once structures have been defined they take time to embed and as part of this transformation, assurance processes have been subject to continual review and challenge to ensure organisational requirements continue to be met.

Focusing on organisations in isolation would not have enabled an integrated picture to be built and interdependencies would not have been fully captured or explored.

The integrated assurance system implemented has allowed for the sharing of best practice in a clear and transparent way across the group.

The next steps are to continue to develop this approach to assurance across the group and solidify the key relationships that have been built. Although this is not the only possible model, it is highly transferable and addresses issues that all bodies working in collaboration will need to address and we will be looking to develop the model/elements of it for broader adoption.

The NHS five-year forward view and more recently the NHS long-term plan have emphasised the need for organisations and systems to work together to transform the way care is provided. All of the shortlisted entries for last year’s HFMA governance award demonstrate not only best practice, but show how working together is key to transforming services.