IGAP - Integrated Governance, Assurance and Performance 

Solving complexity through a governance solution that is simple and effective to deliver outcomes. With a vision to create a truly integrated oversight of governance, with a focus on 360 governance (leadership, vision, risk management, assurance, transparency, openness, honesty, objectivity and accountability) on key business areas and functions; quality and safety, people, finances and resources and regulatory compliance, an innovative governance approach was introduced at Guy's and St Thomas' NHS Trust. Integrated Governance Assurance and Performance (IGAP) was developed. The expected outcome was an ability for a holistic and 360 view, cross-fertilization of impact on key business areas and drawing context and intelligence from the data.

IGAP took the dynamic governance principles forward by creating a fusion between the work of King IV, Nancy Kline’s work on 'Time to Think' through co-creation methodology of engagement with its stakeholders and key members of the committee.

The aim of the project included:

• Removing duplication by removing redundant governance.
• Creating a golden thread that allows a truly bottom up and top down (board-to-ward and ward-to-board) oversight of key issues.
• Enabling conversations by introducing agenda items as questions, using techniques from Nancy's work.
• Using the principles of integrated reporting in a slight variation that enables cross fertilisation of ideas and impact across key business areas of quality and safety, people, operational performance and finance and resource.

During the course of this project, our own list of capital which are linked to our key business domains that we operate under. These key areas of business were identified as:

• Quality and safety – our number one priority.
• People – similar to human capital and our largest spend.
• Operational performance – like manufacturing capital.
• Finance – which included innovative ideas and transformation.

Through the means of the existing resources, a governance and oversight framework was built where all 93 services which are categorized under eight large directorates reported against defined metrics against the above headings. Though, 80% of assurance was sought from quantitative data the crucial 20% assurance was built from qualitative data such as patient feedback, stake holder engagement, staff concerns raised, working with system partners and intelligence held by our regulators.

A perfect fusion of the concepts of integrated reporting framework (IRF) from King IV, Nancy Kline's "Thinking Space" and co-production methodology enabled a tailor made effective solution that was fit for purpose. Thinking is the management skill that is practiced not too often due to the nature of the work and reacting to situations. However, thinking time well spent sharpened our thought process and allowed our senior leadership team to become visionary leaders.

Some of the early benefit realized includes:

• Effective and efficient meetings where every minute is utilized to think and consider all aspects of business in an integrated way.
• Clarified accountabilities, where solutions are owned locally by the leadership teams.
• Improved communication and transparency where all involved worked through a single version of the truth with a single filtration process that enables cross fertilisation.
• Open culture where challenge becomes second nature and conversations are focused, away from omni combatant approach towards collective team accountability.
• Risk driven business planning and running of the core activities.
• Effective and meaningful escalations, where key themes are identified and reported to the management.
• Lastly, governance structure that is purposeful and aligned to strategic vision fulfilment.

Resources: 

Powerpoint: IGAP summary

Podcast: The Better Boards Podcast: Governance - Wicked Challenges in Healthcare

Document: GSTT Project of the Year nomination detailing IGAP. 

Images: Guys' main entrance and A&E exterior. 

Homerton Healthcare within the City and Hackney place-based partnership

Homerton Healthcare NHS Foundation Trust (Homerton Healthcare) provides acute and community health services to the population of City and Hackney. Hackney is a diverse borough with some extreme deprivation. We have long recognised the need for a partnership between health, local authorities and the voluntary sector to address health inequalities in the local population. The trust's leadership team and Homerton Healthcare board of directors have therefore driven the development of the City and Hackney place-based partnership. Although many place-based partnerships exist across the country, we want to showcase the extent to which Homerton Healthcare is fully embedded within the local place partnership – demonstrated as follows:

• The chief executive of Homerton Healthcare is the place leader in City and Hackney, a position that she was nominated for by other organisations in the place. The chair of Homerton Healthcare board sits on the place-based partnership board.  The place director of delivery and place clinical director are both employed by Homerton Healthcare, with accountability to the partnership. 
• The place partnership oversees health and care in City and Hackney. It holds a pooled budget with the local authority and in 2023-24 will receive further delegation for local health spend from the North East London integrated care board (ICB). The structure breaks down old commissioner/provider relationships and enables the partnership to work collectively to determine the best use of resources.
• Homerton Healthcare board of directors were closely involved in the development of the place strategy and have ensured that there is alignment between the Place strategy and the Homerton's own organisational strategy. This gives a clear direction to trust teams and ensures that Place is not an added extra but an integral part of each person’s role.

Evidence of the impact of the partnership is seen in our neighbourhoods model. Place partners have implemented eight neighbourhoods aligned with primary care networks.  These deliver local, integrated services, and provide infrastructure to address localised health inequalities. Many community health, social care and voluntary sector services are now delivered on a neighbourhood footprint. Homerton Healthcare has been a leading partner in implementing the model, working closely with primary care under strong direction and leadership from Homerton Healthcare board.  This evidences our role as system leaders in integrated care, the level of alignment between trust and partnership ambitions, and how we have delivered transformation within our services to deliver partnership aims and address health inequalities.

Committee collaboration in a group model

The appointment of a shared trust chair in 2018 provided impetus for Kettering and Northampton hospitals to improve services through collaboration not competition, which led to the announcement of a group collaboration in 2021. Our challenge has been to adapt our Governance framework to facilitate group working in organisations subject to different regulatory requirements (foundation trust, NHS trust), whilst retaining accountability and oversight within each hospital.

The Trusts held clinical conferences which identified a desire to collaborate and a plea to integrate enabling support functions to achieve this. We set up a collaboration programme committee, initially co-chaired by the chief executives, which brought together both executive teams to identify the first tranche of collaborative services. Boards agreed the principles of group working in late 2019, and a group chief executive joined in 2020, following which directors of governance explored group models from around England to learn lessons to inform our programme.

In 2020, we established Group People and Digital Hospital Committees in Common, which came together to drive work to prepare a group people plan and digital strategy for the group.

In 2021, we piloted a combination of trust-only and group finance and quality committees meeting alternately with each trust appointing a non-executive chair, one of whom convened each meeting. This model caused confusion between the purpose and roles of the group and trust committees and resulted in the duplication of existing standalone assurance reports, leading to overlong agenda which prevented non-executives from obtaining the assurance they required.

We paused 'in common' working for these committees in response in 2022, and held developmental workshops for trust executives to build shared reports and both trusts to consider what good 'in common' working looked like at a structural and cultural level. The outputs of this work enabled in-common working to resume in January 2023, initially on a trial basis.

The pilot resumption of 'in common' working has been a success, with respondents to a recent self-evaluation advising that the new committees had 'definitely improved communication and transparency across the organisations' and had 'improved the level of input from all involved'. The ultimate aim of this approach is to ensure successful collaboration and service transformation for the benefit of staff and patients and, while this remains a work in progress, our efforts and learning over the past five years have formed a sound basis for achieving this.

Provider collaborative

Our Lancashire and South Cumbria, Specialist Mental Health (SMH) Provider Collaborative launched in late 2021, formally taking on some of NHS England commissioning responsibility for adult forensic and tier 4 children and young people's mental health services mental health Services. The trust board agreed to the development and have recruited to a delineated commissioning function within the organisation. This new provider collaborative approach required a paradigm change to the governance within the organisation and in the way specialist mental health services are commissioned and provided across differing stakeholders.

Our new governance approach ensures a sharing of responsibilities and decision-making between different NHS, non-NHS and partner organisations involved in the commissioning and provision of SMH services.

In the context of SMH, this means true partnership working to ensure that patients receive the support they need to manage their conditions and improve their overall wellbeing. One important aspect of collaborative governance is our partnership with non-NHS providers, to bring together different perspectives and resources to address complex challenges in specialist mental health provision.

We believe that effective collaborative governance requires a shared vision, clear goals, and strong authentic communication between partners. We have constituted a collaborative partnership board bringing together representatives from within our organisation (provider and commissioner), non-NHS providers, and other stakeholders to oversee the delivery of specialist mental health services for our local patients, including attendance by people with lived experience of our services.

The partnership board is responsible for ensuring that our services are delivered in line with national and local policies and guidelines, and for identifying areas where we can improve the quality and accessibility of our services. Recent projects have included:

• Commissioning of a two year pilot for 'safe beds' with the voluntary sector, supporting 16-18 year olds who need short stay supportive accommodation.
• Following a patient story received by the board, we commissioned a Health and Wellbeing initiative with Creative Football community interest company, to support secure inpatients with physical activity.

Effective communication is key to successful collaborative governance. Our partnership board holds regular meetings to discuss progress, identify challenges, and agree on solutions. We regularly review our processes and outcomes to identify areas for improvement, and we seek feedback from service users and other stakeholders to ensure that all our services are meeting their needs. By working collaboratively with our non-NHS partners, we can build a stronger, more responsive SMH system that delivers high-quality care and improved outcomes. 

Finally, we know that effective collaborative governance requires a commitment to continuous learning & improvement. Through these relationships, we will develop a shared understanding of the challenges and opportunities and continue to work together to find innovative solutions through co-production, delivery and evaluation.

Resources: 

PowerPoint: LSC Specialised Services Provider Collaborative diagram.

Increasing diversity in decision-making

At Oxleas, we wanted to increase the diversity of colleagues influencing decision-making, create more opportunities and reduce barriers for career development. In 2020, we introduced our shadow executive.  This is a group of 12 individuals who bring fresh perspectives to our executive decision-making.  Applications come from any staff members interested in contributing their viewpoints. Members were selected to represent a wide range of backgrounds, protected characteristics, professions and locations.  They reflect the glorious diversity of our trust, with almost 50% of members from black, Asian, minority ethnic backgrounds and including members with experience of serious mental health issues, members from the traveller community, members from the LGBTQ+ community, members with disabilities and more.

Membership lasts for 12 months. We are now on our third successful cohort.  Each month, the group reviews papers for our formal executive meeting and gives feedback direct to our chief executive and executive colleagues. It is always a lively and enthusiastic discussion.  Their ideas are fed directly to formal executive the next day. The shadow executive can see from the meeting minutes the substantial impact of their insights on the organisation's decisions.

The innovation has been warmly welcomed by our staff networks, who are delighted to see the views of different communities influencing decision-making. The individuals involved in the shadow executive give regular feedback and have been hugely positive. 100% enjoyed the experience. When asked what they valued most, one member said, "I have enjoyed working with the executive team, as they have taken us seriously and really valued our input."

Members have learnt about the organisation, developed skills such as effective chairing and understanding finance.  They have gained insight into the challenges of senior leadership, developed expertise and confidence and built excellent relationships with chief executive and board members. It has helped some re-evaluate career options and many have gone to more challenging/senior roles.

Our decision-making has also improved.  We consider a much broader range of viewpoints and have implemented some excellent ideas from the shadow executive, including our approach to vaccination, use of charitable funds, strategy implementation and more. The shadow executive are sought out as a sounding board when developing new thinking.

The shadow executive is part of a wider diversity programme that has delivered substantial improvements to the culture of the organisation, staff and patient experience. Our 2022 staff survey results are some of the best in the country.

The shadow executive is a public demonstration of our commitment to listening and valuing a range of viewpoints.  Our values (We’re Kind / We’re Fair / We Listen / We Care) seek to embed kindness, caring and inclusion in all that we do. The last word goes to a member of the 2022 Shadow Executive: "I think the idea of the shadow executive is inspired. To provide an opportunity for staff, from a variety of professions and work experience, to contribute to senior discussions shows genuine interest in the staff and value of their input."

Integrated performing reporting for provider collaboratives 

Our South West Provider Collaborative is a partnership of five NHS organisations, one community interest company and two independent sector organisations. We provide a wide-range of mental health, learning disability and autism services to a population of five million people across six integrated care systems.

We have collectively agreed a shared series of strategic aims that has enabled all of our provider partners to unite around a common vision for improving patient services across the South West. Having agreed our strategic aims, we have developed an integrated performance report in the form of a monthly 'slide deck'.

This has enabled us to:

• Monitor delivery of our vision and strategy through aligned reporting and oversight of our strategic aims.
• Develop a shared understanding of progress across all provider partners by providing a clear, concise and consistent view of our overall operational performance, our successes and our key challenges.
• Triangulate data, information and intelligence across a diverse range of domains including operational activity, financial performance, quality and risk.
• Utilising our patient flow system provide information to compare and contrast the respective position of each integrated care system within the collaborative's footprint.
• Support our oversight group (the collaborative's senior decision-making body) to focus its attention on the most important matters and to make collective decisions.
• Provide comprehensive assurance to our Lead Provider (Devon Partnership NHS Trust) that the collaborative is discharging its roles and responsibilities effectively.

Our integrated reporting arrangements have been underpinned by the development of service performance dashboards, which provide a one-page summary of critical information for each service area. This has enabled us to:

• Quickly identify and focus on the key issues relevant to each service.
• Provide clinical leaders with critical information relevant to their services.
• Clearly align our business intelligence to our strategic aims and our risk framework.
• Objectively assess our performance against agreed 'red', 'amber' and 'green' tolerance levels.
• Identify trends or patterns in our activity and/or performance.

Our patient pathway dashboard is the final piece of the jigsaw in our approach to integrated reporting. It provides a visual summary of a patient's journey through our services, as well as offering a useful overview of our activity and performance. It helps us to remain focused on understanding how well our services are performing from the perspective of our patients and service users.

The next stage of development in our reporting will be automation.


Resources: 

PDF: Integrated Reporting in a Provider Collaboration overview slides
Image: SWPC strategic aims 

Integrated performance report

As part of the continuous improvement of our trust’s performance management framework, we identified a need for a more integrated approach to quality and performance assurance and improvement.  It was felt that "performance management" of national and local standards dominated the focus of operational services and that there wasn’t the same emphasis put into understanding the quality of services provided.  There appeared to be almost a "battle" of performance versus quality, rather than seeing the performance as a mechanism that supports quality improvement.  One of the recommended from a governance review also said the board should consider creating a more comprehensive integrated performance report that addresses the live tensions in the organisation as well as its mandated performance targets.  Existing arrangements did not support an integrated approach and to truly "integrate" we needed to understand and be able to triangulate data and information (both qualitative and quantitative) in a way which culminates together to give a clearer picture of the quality and performance of our services. 

The associate director of performance worked collaboratively with members of the board and other key stake holders with the aim of developing an integrated approach to performance that would provide oversight, monitor, and report key measures that demonstrate the delivery of the quality of services we provide and provide assurance to the board through the board subcommittee structure.  The integrated performance approach has led to an integrated performance report (IPR) which includes an integrated board dashboard; demonstrates progress against the long term plan ambitions/system oversight framework; and is supported by reports from each individual board subcommittee.  The dashboard is underpinned by statistical process control charts which has been a positive move away from traditional RAG ratings and has transformed our conversations at board and within care groups.  We also have a performance and controls assurance framework which aligns to our board assurance framework and gives a clear visual representation of where we need to focus our efforts to improve service delivery.

We share our IPRs with our commissioner and integrated care board (ICB) colleagues as a form of assurance that has negated the need for separate reporting which is a huge step forward.  Positive feedback from our staff, our board, ICB colleagues and other mental health trusts on our approach has been overwhelming.  We now intend to continue our journey with the development of subcommittee dashboards to further strengthen our approach.

Resources: 

PDF: TEWV integrated performance approach

Engaging and empowering staff Innovation in technology 

The trust has been working on the following staff engagement activities to improve: 

• Staff morale  
• Communication 
• Staff recognition 
• Increase in survey participation resulting with positive results. 

Work has taken place to develop board, executive team and senior management visibility amongst staff to encourage a two-way communication approach and opportunities for staff to share innovative ideas directly to the executive team.  

The role of the Staff Engagement  Champion was created, where staff at all levels could become a Champion. Individuals with an interest and the willingness to develop engagement within their teams could volunteer to take this role on alongside their daily duties. 
As an outcome of this, in March 2019 the trust achieved: 

• Positive Engagement results from the 2018/19 NHS Staff Survey. 
• National average score of 7.1 out of 10 placing the Trust joint-second most improved staff engagement score in the country. 

The trust's web-based engagement tool, The Bridge has enhanced engagement and staff recognition by enabling: 

• Communication, peer support, access to information and resources e.g. staff surveys and reports  
• Sharing and displaying their individual and team achievements, initiatives, campaigns and ideas 
• New staff network groups e.g. EDI, LGBT+, Carers, Menopause Café, Leadership 
• Appreciation message boards, which have resulted in an increase of survey participation. 

To find out more please send your enquiry to bchft.global@nhs.net

Board Affiliate Pilot Programme

Buckinghamshire Healthcare NHS Trust (BHT) have been piloting a 12-month board affiliate role by integrating a doctor-in-training within its trust board. The board affiliate can attend public and private Board meetings and serve on a sub-committee of the board, which leads onto cohort two of the Trainee Leadership Board (TLB).  

BHT became the first acute trust in Thames Valley to run a 'Trainee Leadership Board'. This project sought to engage doctors-in-training by integrating the theoretical and practical aspects of clinical leadership and then putting it into practice. The TLB recommendations have subsequently been incorporated into the outpatients transformation programme. 

Following the success of the TLB; the trust’s leadership were keen to explore further ways to engage doctors-in-training (and other members of the workforce in the future) with senior leadership.  

This has led to the Board Affiliate Pilot Programme, which offers learning through hands-on experience to develop the skills required for future leadership roles by offering: 

• improved employee engagement,
• increase diversity and background of representation at trust board,
• provide direct insight into day-to-day operations of clinical activity,
• contribute to quality improvement at the trust through the trainee leadership board,
• recognise and support the development of future leaders within the trust,
• raising the profile of BHT,
• contribute to embedding cultural change within BHT. 

Cross-committee working – triangulation, assurance and effectiveness 

The Trust wanted to strengthen the triangulation between board sub-committees and to enhance the effectiveness of the board with an integrated governance at all levels of the trust.  

The following practical steps were put in place:  

• A comprehensive review and revision of the organisation’s governance structure.
• The chairs of the quality, finance and performance, workforce and risk and audit committees were invited to sit on each of the other committees. 
• The committees produced annual workplans accompanied by a narrative outlining the committee’s strategic priorities and how this aligned with the work of the other committees. 
• Items for referral to the board from each sub-board committee meeting included in the Integrated Performance Report to the public board meeting.
• Areas of concern referred back to the committees from the board for deep-dives and further assurance or improvement work. 

Recent examples of benefits and outcomes: 

• Flu vaccination campaign 2019 - The impact of the board’s cultural leadership on this issue is demonstrable in high take-up rate for vaccination 

• Overseas recruitment - cross-committees work enabled the hospital to meet targets set out in the scheme to recruit overseas nurses.

The success to date of this integrated way of committee working provides the board with confidence that the governance foundations are in place to underpin this organisational change. 

To find out more please contact Dorset County Hospital NHS Foundation Trust's Communication team.

Conversation Café

In 2017, the trust's communications team developed a Conversation Café concept, to improve engagement with the wider workforce, which was approved and fully supported by their board, with the following aims:  

• To engage with the wider workforce in a fresh and innovative way that was at their convenience, not just that of the organisation. 
• To increase the visibility and accessibility of senior managers and the board. 
• To listen to staff and talk about topics of importance to them too, not just the organisation, but also to raise awareness of East Midlands Ambulance Service NHS Trust's strategic objectives.  

The concept involves using an East Midlands Ambulance Service NHS Trust vehicle, offering a free hot drink and the opportunity to share views and ideas. Since it’s concept back in 2017, there have been eight completed tours, visiting around eight sites and each time seeing an average of 160 colleagues each tour.  

Over the eight tours, the feedback and ideas staff had provided helped shape the organisation and offer further improvements to patient care. Since the tours started they have received an improved Care Quality Commission rating, which stated that colleagues felt the culture of the organisation had got better over the last two years and noted the Conversation Café concept as an area of outstanding practice. 

To find out more please contact Melanie Wright, Assistant Director of Communications, East Midlands Ambulance Service NHS Trust.

Risk Management - our journey to outstanding 

In 2019 the trust was on their journey to achieving an outstanding rating. To enable them to deliver the ambition set out in the trust strategy and the NHS Plan they produced a risk management strategy to provide high quality services. 

Hounslow and Richmond Community Healthcare NHS Trust recognised that successful risk management must be: 

• forward thinking, 
• the responsibility of all,
• comprehensive and coordinated, 
• proactive, a continuous identification and management of risk is essential to the delivery of high value healthcare. 

The trust's strategy sets out clear goals, achievements and timescales for implementation. This enables staff to work towards the same aims, empowering innovation whilst ensuring patient quality and care are at the centre of delivery.

Building on an already well-developed risk management platform, the trust identified there was one underpinning area for action, to develop an ‘outstanding’ risk management approach with four key areas of focused activity: 

• Internal governance - clear organisational structure with well-defined lines of responsibility.
• Integrated governance - systems to manage and reduce risk across organisational and professional boundaries.
• Enhanced measurement and monitoring – to continuously assess and improve reporting and committee oversight of KPIs, Quality Improvement and regular audit.
• Develop training to increase the knowledge and skills in the workforce.  

To find out more, please contact the Hounslow and Richmond Community Healthcare NHS Trust's Communications team.

A cultural and process improvement to the assurance framework 

Leeds Teaching Hospitals NHS Trust transformed its Framework of Assurance following an external review of the trust’s risk management system, comprising the Board Assurance Framework and Corporate Risk Register. 

The trust accomplished this by: 

• Reducing the number of corporate risks, from almost 100 to less than 25, enabling the executive directors and trust board to focus on the most significant risks. 
• A revision of the Board Assurance Framework, focusing on the 3 key strategic risks: workforce, partnership working and finance.
• Improvement to the trust’s culture, known as the Leeds Way, which has transformed behaviour, working relationships and engagement in the organisation. 

The trust board now takes considerable assurance from the Risk Management Framework including; 

• Identification of risks and their inclusion in relevant risk registers.
• Effective reporting of the Corporate Risk Register and Board Assurance Framework to the trust board, Audit Committee and Risk Management Committee. 
• More accurate and consistent scoring of risks in line with the Risk Management Policy and accompanying Risk Appetite Statement. 
• An effective escalation process for deteriorating risks. 

Progress was noted in CQC's well-led inspection in September 2018. The trust regularly receives approaches from other NHS organisations to study its Risk Management Framework and attend Risk Management Committee, to learn from this good practice. 

Quality Governance and Risk Management - The heat map process 

In 2019 Portsmouth Hospitals NHS Trust refined its quality governance arrangements, to enhance stakeholder engagement and streamline processes.   

They developed a 'heat-map' diagnostic tool, which has the capacity to demonstrate: 

• A number of indicators, displayed by ward and service, grouped into CQC domains. 
• Visual identification of potential areas of concern and/or areas of good practice. 
• Cross-examination of quantitative data and qualitative information (e.g. horizon scanning, feedback from quality reviews, views of experts). 

This has in result improved identification of actual or potential non-compliance with quality standards, enabling effective assessment and triangulation of evidence from a wide range of sources. These results along with an quality issues identified by stakeholders are discussed at the at monthly Shared Assurance and Improvement Programme meetings (SAIP), which are attended by the trust's governance and nursing leads, and representatives of the clinical commissioning groups, NHS England and Healthwatch. 

This approach enables shared analysis of potential or actual areas of concern, and triangulation of collective observations.  

Engagement of key stakeholders during SAIP has benefited the trust effectively deliver: 

• An open and transparent governance structure.  
• A system to identify key areas of commendation and improvement.
• A proactive approach in focussing on matters arising, rather than a pre-determined work programme. 

Achieving good governance through Freedom To Speak Up 

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH) set out to achieve improvement in risk identification and to establish enhanced patient safety pathways from a multi-provider perspective specifically linked with integrated care systems, sustainability and transformation plans and primary care developments.  

The trust’s board of directors defined that taking this integrated approach was essential to meet the priorities initially in the five year forward view and more recently defined in the NHS long term plan.  

The trust achieved this by: 

• Restructuring existing teams for cultural improvement.
• Dispersed leadership and introduced Freedom To Speak Up (FTSU) champion roles, from a diverse skill mix, seniority and geographical location enabling appropriate visual leadership. 

This approach and implementation of FTSU role has resulted in a number of benefits for patients, staff and also joint working, which include: 

• A 41.5% increase in early patient safety incident reporting.
• A 24% reduction in patient complaints, with an increase of 21% in the use of the Patient Advice and Liaison Service indicating earlier resolution is being sought.
• Clear escalation systems have been developed.
• Reporting systems regularly reviewed to ensure continual service improvement.
• Sharing of good practices on FTSU with neighbouring Trust to making systematic improvements to patient care internally and outside organisational boundaries. 
• Development of people has been provided in a cost effective manner encouraging partnership working. 

The Trust was awarded the HSJ FTSU Organisation of the Year Award in November 2019. 

Care Together - an integrated approach to health and care  

Tameside and Glossop Integrated Care Foundation Trust (T&G) has undertaken significant transformation to develop an integrated model of care to their population. Their 'Care Together' Programme is an innovative, whole health and care system programme to transform the way in which services, care for, involve and support the 250,000 residents, to improve health and wellbeing and supporting financial sustainability.  

Tameside and Glossop Commissioner and trust boards have been working together for three years to bring about cultural and behavioural change, which have given colleagues working on the front line the ‘permission’ to go out and try new ways of working for the benefit of the population.  

T&G has also introduced informal governance to allow for shared decision making. Alongside this, they have established a Partnership Engagement Network (PEN). The PEN provides the public and their partners with a structured method to influence the work of public services and to proactively feed in issues and ideas. T&G are recognised as a leading locality in integrated care and have shared their learning with national and international teams.  

This was also recognised with the Trust and Local Authority CEO's won the Greater Manchester award for 'leaders across boundaries' in 2019.

Harnessing patient and clinically-led system-wide change

Walsall Together is an Integrated Care Partnership that aims to develop new integrated ways of working to: 

• improve the health and wellbeing outcomes of the Walsall population, 
• increase the quality of care provided, 
• and provide long term financial sustainability for the system. 

The Walsall Together Partnership has made significant progress in delivering service transformation across the target Clinical Operating Model: 

• Integration of specialist nursing services for Respiratory and Cardiology. 
• Healthwatch has been commissioned to develop a Walsall Together User Group ensuring public and patients contribute to the identified priorities for service redesign. 
• Agreement on a combined infrastructure to support a Shared Care Record and Population Health Management has been reached. 
• Walsall Together Partnership and joint governance arrangements enabled a successfully Family Safeguarding Model bid to transform services (designed by citizens for citizens).
• As a starting point for the implementation of a Single Point of Access, a pilot has been developed for Winter 2019/20, with a specific remit of admissions avoidance. 
• Improvement Plans for the integrated care service and wider therapy services have been agreed and project groups have been established to assure implementation. 

Provider collaboration supporting system-wide working 

Providers in West Yorkshire and Harrogate (WY&H) have joined up care to improve outcomes by tackling big health and care challenges and making best use of resources.

WY&H have invested heavily in relationships, bringing leaders together to tackle system-wide issues at monthly leadership days. The formal governance arrangements are built on these strong relationships.

Collaborative working and collective decision-making have resulted in:  

• Forecast achievement of single control total, maximising provider sustainability funding. 
• £35m in capital investment. 
• Collaborative procurement, saving trusts around £1m a year by standardising and reducing costs for goods and services. 
• A workforce portability agreement, allowing trust employees to work for any other trust without the need for honorary contracts.
• A single service model for vascular services and better stroke services.
• Two new WY&H care models for Adult Eating Disorders and Tier 4 Child and Adolescent Mental Health Services (CAMHS). These have reduced admissions (22% in eating disorders, 19% in CAMHS).
• A preferred model for the future provision of Assessment & Treatment units for people with a Learning Disability. This includes how the three existing (and two future) geographically dispersed units will operate as one WY&H centre of excellence. We are now engaging further on this. 

A radical new approach to governance and management powered by intelligent use of IT 

As part of the preparations for the Wirral Community Health and Care NHS Foundation Trust to achieve Foundation Trust status in 2016, a new governance structure was put in place to meet the requirements at the time. This structure complied with NHS guidelines but was very traditional and heavy in terms of administrative load and paperwork.

The trust introduced changes, and tweaked the arrangements to optimise the effectiveness of the new approach, they commissioned an independent audit of the new and radical approach to management and governance by MIAA, these included: 

• Developing a Trust Information Gateway, based on YellowFin software, which provides very current data to all interested parties in numerical, traffic light assessment and trend formats to be used in real-time at all scrutiny and management meetings.
• Radically reviewing all conventional committee structure operations.
• Introducing a SAFE system, to monitor clinical compliance against their clinical governance framework, that presents data in real-time to any relevant party. 

The new system has reduced unnecessary administrative burden on the trust and has delivered critical information to all in real time. Most importantly the new system has built in a culture of informed positive professional challenge and support, combined with routine review of process and enhancement.