Integrated Governance

The key to effective integrated governance is to stop the unintegrated governance at the same time.

In any integrated care initiative people create new committees, boards and teams. If you just add these onto existing lines of responsibility then all you are doing is adding more meetings and layers of bureaucracy. Make sure the new replaces rather than overlays existing arrangements.

The integrated governance in an alliance is relatively simple. An Alliance Leadership Team (ALT) is responsible for ensuring delivery of the outcomes and an Alliance Management Team (AMT) is responsible for delivery itself. Both teams have representatives from each of the parties who together hold the joint responsibility and therefore have ‘skin in the game’.

When we set up a new alliance way of working we strongly encourage the early formation of ‘shadow’ Alliance Teams. By setting these up before the contract start, those people who will be responsible in the future have to negotiate the detail together. The shadow ALT finalises the contract and commercial arrangements, the shadow AMT focus on the service design and implementation. It helps to divide up the work and we find people are focused and move at pace.

Working through these is a positive relationship building exercise. People come to understand each other’s perspectives, to make ‘best for system’ decisions and explore the art of the possible rather than take entrenched positions. By the time the contract starts, good relationships and collaborative behaviours have developed. Everyone will have been on the journey; it is real.

It is critical that everyone uses governance well. This can be tricky in the pre contract phase as there is no true change from mono to integrated accountability. It is surprisingly easy for old dialogues to reopen or even to never stop in the first place. For instance there might be a unilateral dialogue between one provider and the commissioner or between the commissioner and provider finance leads. Changes and deals agreed in these ‘outside integrated governance’ will undermine true collective decision making that is essential for building trust and collaboration.

Once the contract is up and running all commissioner-provider discussions and monitoring of the services go via the Alliance Leadership Team. Any one-to-one contract monitoring meetings must no longer include discussions about the services that have moved into the alliance scope and thus under the integrated governance.

As one commissioner leader said recently to me as she had that ‘aha moment’ – “I get it now, I’ll only ever speak about those services at the Alliance Leadership Team, not in our trust contract monitoring meetings”. Exactly.

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