Feature / Mind the gap

Across the world there is a recognition that care needs to be co-ordinated around the needs of patients. This is not an argument for structural mergers but a recognition – particularly with chronic illness and the elderly – that different parts of the patient pathway will be delivered by different service providers.

Governance in an organisation has always been important in ensuring the right outcomes are delivered to patients or service users and providing assurance about services. But integrating services around patients – the government said in May it wants to realise this by 2018 – means leaders need to think about governance between organisations as well.

Governance between organisations (GBO) is a term developed by thinktank the Good Governance Institute (GGI) to capture the governance and accountability issues relating to decisions being taken by more than one organisation. In essence we are talking about the governance of whole systems, ensuring continuity of care and guarding against patients falling through the gaps between organisations.

Diabetes is a good example of a service with a complex range of demands and providers (see Diabetes UK web of care, right). But it is not the only example. And integration issues are not confined just to the English healthcare system, where there is arguably greater structural fragmentation. The rest of the UK, where single-system working is the core model, is also having to focus more on shared or devolved decision-taking.

In many areas of the NHS, the requirement to streamline decision-making, reduce bureaucracy and support partnership working has created a situation where decisions are often taken by others on behalf of the accountable body.

For example, a newly created clinical commissioning group (CCG) in England can expect decisions to be taken on behalf of its population by a wide range of organisations – NHS England, commissioning support units (CSUs), local authorities and other CCGs leading on specific services.

The public sector may understand the need to work together, but it often produces tensions at organisational boundaries – it can be unclear where accountability lies and who is in charge. However, it is these handover points between organisations or individuals that matter to patients (see the EU-funded handover project at www.handover.eu).

Patients and service users find it frustrating their care falls between the cracks or their case disappears into a black hole. Misunderstandings or a lack of co-ordination inevitably lead to delays for some. At the same time, it is these fissures between services that can offer organisations the greatest potential for improvement.

It was a point underlined by Sir David Nicholson, while still at the Department of Health. In the 2010/11 operating framework, the then NHS chief executive (now at NHS England) said: ‘The quality and productivity gains we need to make lie not within individual NHS organisations but at the interfaces between primary and secondary care, between health and social care, and between empowered patients and the NHS.’

Providers are also increasingly entering into partnerships and joining academic and innovation networks that require commitment to agreed principles. The Birmingham and Solihull NHS cluster identified joint goals requiring ‘all commissioners and providers to work to improve patient experience and service quality through models of care based on choice and shared decision-making’.

It is important to remember that setting up and managing partnerships is about delivering change. Its success depends on:

• A shared sense of purpose and vision
• Clear ownership and commitment
• Strong governance and inter-organisational relationships
• Clear accountabilities and delegated authority
• Jointly owned and focused agendas and business plans
• Effective inter-agency and community-wide engagement and communications.

Even given the supportive rhetoric often surrounding collaboration, one must look out for, and deal with, the barriers that need to be overcome. We all have a responsibility to provide high-quality, joined-up services that better meet patient needs. But inquiries into service failure and financial meltdown often highlight failures in communication and isolated islands of planning and accountability. Having a sound approach to GBO will help avoid such pitfalls.

Through the GGI’s work with CCGs, CSUs and providers, we have developed a table of questions and answers (above) and a maturity matrix (below). These are designed to provide practical guidance to NHS governing bodies, local authorities and partnerships. They will help them reflect on their joint decision-making process and ensure they are getting the right answers when dealing with issues that extend beyond their set boundaries.

It is important to remember that although all statutory bodies can decide locally how they carry out their functions, they cannot absolve themselves of responsibility. This was made clear in the Department’s 2012 guidance for CCGs, The functions of clinical commissioning groups, and NHS England’s CCG assurance framework 2013/14. In practice, this means that when decisions and actions are taken elsewhere it is essential that the statutory body explicitly sets out its risk appetite and tolerance levels and has effective systems in place to map accountabilities and track decisions and outcomes. 

Dr John Bullivant is chair of the Good GovernanceInstitute. GGI chief executive Andrew Corbett-Nolan andMike Ponton, former director of the Welsh NHS Confederation, also contributed to the work behind this article