Partnership working - NHS perspective

The 2022 Health and Care Act introduced new legislative measures that aim to make it easier for health and care organisations to deliver joined-up care for people who rely on multiple different services. The NHS is in the process of adjusting to the latest structural change, with the demise of Clinical Commissioning Groups and the establishment from July 2022 of Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs).

With the creation of Integrated Care Systems (ICS), ICBs and ICPs, the NHS is experiencing a far greater focus on collaboration than ever before. From July 2022, all NHS trusts providing acute and mental health services needed to join a provider collaborative. NHS community and ambulance trusts and non-NHS providers, such as voluntary, community and social enterprise (VCSE) sector organisations or independent providers, are offered the opportunity to take part where this will benefit patients and makes sense for the providers.

Partnership working has always been an aspiration and supported through initiatives such as the better care fund collaboration with local authorities, and there are examples of jointly-funded senior posts between the NHS and councils. The new arrangements put collaboration and partnership working at the forefront of the agenda to provide a more cohesive, joined-up approach to health and social care service delivery. ICPs are the vehicle for engaging with stakeholders across the wider health and social care sectors, including the independent and VCSE sectors.

The new arrangements present a new dynamic in terms of culture, governance and risk, and internal auditors will need to evaluate partnership working in that context. There are a number of things to be mindful of:

• Each organisation is a legal entity in its own right, with its own statutory duties and unique objectives. This may lead to conflicting priorities between partner organisations and a risk that effective outcomes for the wider health and care system, and its population, are more difficult to achieve.
• Different cultures. Culture tends to be driven from the top of the organisation, and is inevitably influenced by factors such as key responsibilities and accountability. An obvious example is that NHS organisations are accountable to NHS England (and upwards to the DHSC and Secretary of State), whereas local authorities have elected members accountable to, and reliant on, the support of their local population. Arguably there is a political influence on both, but with different dynamics at play.
• Other sectors are more disparate and numerous, and often will not have the management or operational capacity of an NHS organisation or local authority. Their ability to influence the agenda may then be limited and diluted, with a risk that they may feel disenfranchised. This in turn risks reducing the value that they can add to decision-making and service delivery across the wider system.
• The capacity of key individuals to operate effectively in partnership roles in addition to an already demanding substantive role (the day to day, core position to which a staff member has been appointed (or would normally occupy) on a permanent basis).
• Decision-making structures need to be clear and transparent, with due regard to potential and perceived conflicts of interest which risk compromising the integrity of decision-making.
• Difficulties and delay in reaching decisions where a number of stakeholders are involved with different or conflicting aims and objectives.
• The opportunities from greater partnership working are potentially significant, with the combined resources of different sectors working to the same overall objectives. There is an opportunity to break down traditional barriers and to create better understanding of the challenges facing the health and care sector, and to develop effective, joined-up strategies to address them.

As organisations work more closely in partnership, a clear understanding of system risks, how they impact on each organisation and how they will be managed, including how interdependencies are managed, is important.

Internal Audit has a key role to play by providing independent assurance on the effectiveness of partnership working arrangements. A good starting point will be to evaluate the governance arrangements established for partnership working, such as memorandums of understanding, partnership group or committee terms of reference, strategy and policy, conflicts of interest policy, decision-making and risk sharing protocols; and to test their operation in practice.

A challenge for effective partnership working, as with any system or process, is to ensure clarity of purpose through an agreed set of objectives, supported by effective tactical plans and performance outcome measures that are capable of demonstrating progress. Internal Audit should review these arrangements and provide assurance on the integrity of the management information being relied on for review and decision-making purposes.

Integrated Care System

https://www.england.nhs.uk/integratedcare/what-is-integrated-care/

https://www.nhsconfed.org/publications/integrated-care-systems-ics

Integrated Care Boards

https://digital.nhs.uk/services/organisation-data-service/integrated-care-boards