Corporate governance should have clear lines of accountability through the organisation, starting at the highest level and supported by robust policies and procedures. It should ensure that resources are well-managed and that the operational plan is delivered.
In our research nationally and internationally the messages were the same:
- Corporate, clinical and organisational standards need to be set corporately and cascaded across the network before you mobilise.
- Common delivery frameworks are needed to compare performance standards across a network.
- Strong clinical governance and organisational policies should set working standards and staff expectations.
- Geography should not be a barrier to delivering replicable quality and performance standards, sustaining reputation or to an organisation-wide performance framework.
- To date Moorfields has prioritised clear governance accountability for networked services by securing ownership of the activity, staff and equipment.
- Our experience has been that hybrid versions, such as the host retaining the activity, blurs the lines.
- Even where we have ownership there can be issues with host trust deliverables such as space availability, medical cover and IT support. Having a service level agreement does not guarantee that the supporting services will be consistently delivered.
- Board executives we spoke to had different ideas on what a governance model should look like from a ‘light touch’ once a year CEO-to-CEO meeting to a joint board to oversee the working arrangement. The views seemed to reflect positive or negative experiences of working with other organisations.
- One global healthcare organisation told us it never entered a partnership where it had less than a 51% share, ensuring it had overall control.
- Another international healthcare organisation had a clear strategy for increasing market share but had not at the time considered the benefits of a networked care strategy. It was now retrospectively creating network governance.
- We rarely encountered a networked care solution that did not arise from a need to improve or sustain the service.
- A networked care solution can help a service that is failing, perhaps because it cannot recruit or because of its clinical clinical governance arrangements.
A symptom of service failure (or perceived failure) is a lack of trust between corporate and clinical delivery teams. It may indicate that the way in which corporate and clinical governance co-exist is not understood and respected inside the organisation, that corporate or clinical governance is not well managed or that the boundaries between corporate and clinical governance are not clearly understood.
This toolkit is mainly focused on the single specialty networked care model which presents additional challenges for governance compliance as two organisations are involved. There are a number of possible models but whether the specialty provider takes over the host trust’s service in all respects or there is some other partnership agreement the questions remain the same:
- How do you align the two organisations policies without creating a burden on staff or line management?
- What about the policies which relate to where you work physically? Whose fire policy applies? Whose mandatory training is more relevant?
- Do incidents have to be reported twice?
- Who do you go to with a safeguarding problem?
Do not underestimate the detail that needs to be considered and the need for the two organisations to work through these issues together. Running a service independently of the host trust may seem to be a clean solution but in practice there are a number of ways in which collaboration may improve staff experience and reduce duplicated costs.
At all times the following principles might help to keep the relationship on track:
- Work together to ensure the service is well understood and that potential problems are mitigated before mobilisation.
- Make sure all the relevant stakeholders internally and externally are involved and/or communicated with.
- Be clear about the form of relationship and have clear accountabilities to each other: staff at both trusts, patients and other stakeholders.Everyone needs to understand who is in charge of the service.
- Treat each other with respect – the leadership behaviours will be clear to staff on the ground and tensions may affect their ability to deliver the service.
- Be open and transparent.
“All our historical growth is based on business cases, not a planned network. With hindsight we made a mistake not to proactively plan and design as a network and so we are now designing retrospectively while operating services.”