Governance between organisations: Consensus on effective practice Post-launch briefing for the governance between organisations programme launched at the Royal College of Physicians, 2nd July 2008 Background
Governance between organisations (GBO) is the second stage in the development of integrated governance. Building on the work that led to the launch of the Department of Health Integrated Governance Handbook (February 2006 - Gateway reference 5947), GBO takes the next step in the good governance odyssey and looks at the all too tractable issues around ensuring accountability in services that will inevitably be provided by a network of different organisations. Care is a complex industry: and a continuing and potent cause of service failures arises from the handover points in the care pathway from one organisation to another.
The agenda for the governance between organisations programme was set out in a debate paper1 launched at the NHS Confederation. This identified the themes of:
- Continuity of care
- Partnership and supplier relationships
- Business continuity and mutual aid
All of which, would benefit from working through both policy and practical governance issues.
The Institute of Healthcare Management hosted an in-depth conference at the Royal College of Physicians to initiate this debate.
In the opening address, Lord Newby of Rothwell outlined the case for this work. For a full copy of his address to the conference, please click here. There has been record investment in healthcare, and the perception is that delivery has not matched expectation. The future for effective care delivery was going to be a team effort between the public, private and third sectors. Thus putting in effort to working through the effective inter-organisational governance was critical. Citing examples from other sectors such as the School Food Trust and Northern Rock he analysed the difficulties when partnership arrangements come undone. He set out an agenda of the ten most common pitfalls in partnership working which he hoped the GBO programme would incorporate. These are:
- No common ethos
- Silo mentality
- Unclear division of responsibilities
- Lack of rules
- Lack of leadership
- Lack of resources
- Lack of time
- Conflicting egos/ambitions
- Lack of incentives and penalties
- Lack of precedent
Taking the first of the main themes of governance between organisations, Andrew Corbett-Nolan, the Chair of the Institute of Healthcare Management cited the case of a recent patient in Lambeth and a neighbour of his. A long-term patient with chronic obstructive pulmonary disease “Eunice” had complex care needs. She lived in a large Council flat at the top of a block, and relied for transport on a motorised chair which would not fit in the lifts of her flat: thus it was difficult for her to charge the machine. Her housing and social care needs (for example, she had problems with shopping, laundry, etc) made her depressed and reliant on friends at a local pub where she also charged her chair. However, often simple problems could only be resolved through medical intervention and in her last year of life she had six acute episodes leading to hospitalisation. Efforts to resolve all of her care needs were bounced between general practice, hospital, community nursing, social support, housing and various informal carers with the net-effect that no one person or agency was responsible for her care. Even two months after her death it was proving difficult to arrange a funeral as her nearest relative in Burnley was disabled and there was no one person or agency in charge of arranging her funeral. In short, no one was governing either her last years of life or death.
This theme was picked up by later speakers. Anna Walker, the chief executive of the Healthcare Commission, identified that an analysis of serious service failures pointed to the handover between care agencies as a persistent problem. She looked forward to a more joined up inspection regime, where a new regulator would have greater powers to intervene where there was no obvious locus of responsibility. Dr. Adrian Bull, the Medical Director of Humana, continued this theme by examining the Victoria Climbie case where despite being well known to services a vulnerable child had been badly let down through no one agency taking the lead.
Partnerships and supplier relations formed much of the discussion in the workshop session led by Dr. John Bullivant. Too often the healthcare model was to consider the job done when a patient was passed on to another care provider (eg, such as in a referral from a general practitioner to hospital service) rather than checking that the patient had been taken up by the new service and their problem was being solved. Dr. Bullivant used the analogy of two climbers, where both would check in a climb that the rope was secure (“have you got the rope?” – “yes, I have the rope”). High risk industries were used to check-lists and checking back as a way of ensuring quality. Partnership arrangements and transactions along the supply line too often were characterised in the care industry by referral mechanisms being passive.
Moving on to talk about contracting out, Dr. Bullivant felt that health had much to learn from local authorities and the Best Value programmes, whereby where a service was required the authority would decide whether that were best provided by itself, and if not how alternative suppliers could be brought into the market to supply needs effectively, economically and for the long term. This he considered moved commissioning on from a world of annual contracts to one of the concept of funding, whereby the PCT would act in a proactive and strategic manner to create both a market and a supply source to meet the care needs of the local population.
This linked to the last main plank of integrated governance, the issue of business continuity and mutual aid. Care providers had proved themselves to be excellently organised to manage short term crises such as terrorist incidents. It was a credible and remarkable mark of the NHS that in such emergencies plans were in place, and there was a will to manage the crisis regardless of what that took. What was less well tested and rehearsed, though, were long term or geographically specific problems. The floods in Hull, for example, still had much to resolve and were an outbreak of avian flu to bring a whole part of the country to a halt what would be the response, indeed duty as a corporate neighbour, of other more remote parts of the service. So were Norfolk down for six months, what would the appropriate response be from Liverpool?
The governance between organisations debate paper raised many accountability issues for NHS organisations and local authorities to think through. In the coming months there would be a programme to explore these issues and develop various tools to support local decision making. The Institute of Healthcare Management will be taking forward this interest in the new governance construct. Speaking on behalf of the authors of the debate paper, Professor Michael Deighan identified that in the remainder of 2008 there would be series of regional workshops and discussion forums. Those in PCTs, NHS providers, the private sector and social care organisations would be asked to contribute to how the agenda was developed. Board assurance products were now available and were launched at the conference which identified the main issues which boards were invited to consider when promoting better joined-up governance thinking across organisational divides. Likewise an etiquette guide for partnership governance was now available. A maturity matrix was being developed by the Benchmarking Institute which would enable boards to understand where they stood against good governance between organisations practice, and agree what developmental steps they needed to take.
The governance between organisations issues raised in the conference were some of the most testing developmental tasks that facing those transforming health and social care. At the heart of accountability for good patient care, this agenda needs to be considered by those leading healthcare organisations. The Institute of Healthcare Management will be contributing to future developments, and encourages its members to understand the issues and identify better practice that others can learn from. Over the coming months, the Institute will be promoting the debate paper and working up guidance and case studies for managers to apply.
1 “Integrated Governance II: Governance Between Organisations”, Dr. John Bullivant, Professor Michael Deighan, Professor Bryan Stoten and Andrew Corbett-Nolan; published June 2008 by the Institute of Healthcare Management
