Key indicators
FIGURE 13
- Close to two thirds (65%) of respondents agreed or strongly agreed that their trust board can influence the decisions made in the systems they are part of. This was the strongest agreement level of all statements. Last year a similar statement ‘The trust board can influence the development of the system(s) we are part of’ also received the highest level of agreement (68%), although the change in wording from ‘development of’ to ‘influence the decisions made’ means the proportions across years
cannot be directly compared. - Slightly over a third (35%) of respondents agree that the trust board is confident that risk is managed effectively across the system(s), compared to 12% last year. A similar proportion disagreed with this statement compared to last year (2024: 24%, 2023: 28%) and respondents were less likely to be neutral (2024: 41%, 2023:57%), suggesting that responses to this statement are more polarised this year.
- Half of respondents (50%) agreed that the trust board is confident that conflicts of interest are managed effectively across the system(s) up from 40% in 2023. Respondents were less likely to be negative about this statement than in 2023 (2024: 7%, 2023: 18%).
- Respondents were more likely to agree that ‘My trust has found the guidance from NHS England relating to system working helpful’ this year (42%), compared to 2023 (32%).
- Nearly a quarter of respondents (24%) agree that the trust board has confidence in how continuous improvement is managed across the system(s). As with last year, it remains one of the statements with the smallest proportion of respondents who agree. Three in ten respondents (29%) disagreed with the statement in 2024, the largest disagreement of all statements, which is similar in value and pattern to last year (26%).
- Over half (58%) of respondents agreed that the trust is involved in the ongoing improvement of the governance infrastructure of the system(s). Last year, respondents were asked about their trust’s involvement in the ICB’s work to design the governance infrastructure of the system(s). Although we cannot directly compare the results of different statements, there was also a majority (55%) of agreement about their trust’s involvement with the governance infrastructure of the system, albeit the development of it and not the ongoing improvement of it.
The trust board can influence decisions made in the system(s) we are part of
- Compared to the survey average (11%), acute trusts (21%) and acute specialist trusts (22%) were twice as likely to disagree with this statement.
- Agreement overall was (65%). All (100%) ambulance trusts agreed, followed by 88% of community trusts and 77% of combined acute and community trusts.
The trust board is confident that conflicts of interest are managed effectively across the system(s)
- There was 50% agreement overall with this statement However, all (100%) ambulance trusts agreed, 77% of community trusts and 67% of combined mental health/learning disability and community trusts.
The trust board is confident that risk is managed effectively across the system(s)
- Compared to the agreement in the overall sample (35%), community trust (55%) and combined mental health/learning disability and community trust (50%) were more likely to agree with this statement.
The trust is involved in the ongoing improvement of the governance infrastructure of the system(s)
- A higher proportion of combined mental health/learning disability and community trusts disagreed (36%) with this statement than other trust types and the survey average (18%). They were also less likely to agree (43%) than the survey average (58%).
- All (100%) of ambulance trusts and 78% of acute specialist trusts agreed with this statement, the highest of all trust types and above the survey average.
If you disagreed with any of the statements please tell us more, or feel free to explain any of your answers:
- There was an overall sense of lack of clarity and consistency, and that roles are not well-defined, which leads to confusion. Some said that collaborative arrangements are still evolving, so it is too soon to be able to comment.
- Some feel a disconnect between the ICB and trust boards, with limited visibility of collaborative work and lack of involvement of NEDs. Other respondents highlighted that NEDs often feel excluded from system-related roles and responsibilities and so struggle to have their perspectives adequately considered.
- Respondents highlighted the need for a stronger focus on measurable outcomes, as well as more consistency in system processes, including the interplay between provider collaboratives, ICBs and NED involvement.
"Trust chairs are confident about their role in the system, but it is not clear whether the wider NED group is confident about this even with reporting to board and sessions on partnership.”
Company Secretary, Acute Trust
“Provider collaborative arrangements are not yet mature and system incentives continue to encourage optimising local performance at place rather than acting in the interests of the wider ICS population.”
Governance Lead, Combined Acute and Community Trust
“Trust NEDs remain confused about the purposes and capacity of one of the ICBs; the other has largely ignored us and made no effort to involve trust NEDs in any shape or form.”
Chair, Combined Mental Health/Learning Disability and Community Trust
“Lack of clarity as to guidance from ICBs and the role they play in directing strategic planning and implementation.”
Chair, Combined Acute and Community Trust
FIGURE 14
- Two thirds of trusts (67%) agreed or strongly agreed that 'The collaboratives and partnerships the trust is part of refer back to my trust board (deliberative decision-making) when making high-risk decisions', which is the highest agreement of any statement, and similar to 2023 (66%).
- Close to two thirds (66%) of trusts agreed with the statement ‘the trust board is confident that any collaboratives or partnerships the trust is involved in are working on the right priorities for patients’, compared with 59% in 2023.
- The majority of respondents (59%) agreed that their trust boards are ‘confident that any collaboratives or partnerships the trust is involved in are delivering measurable patient benefits’, which is higher last year, where 38% agreed or strongly agreed with this statement.
- Over half (53%) of respondents agreed that their trusts were ‘confident that the ICB trust partner member(s) will appropriately contribute the perspective of relevant trusts to ICB decision-making’, a similar proportion to last year.
- Respondents were least likely agree, and most likely to disagree, with the statement ‘The trust board is confident that there are clear roles for trusts, ICBs, integrated care partnerships (ICPs), place-based partnerships and collaboratives’ (agree/strongly agree: 39%, disagree/strongly disagree: 21%). These proportions are broadly in line with last year’s results for this statement (agree/strongly agree: 35%, disagree/strongly disagree:16%).
How many of the following is your organisation a part of:
Do you have board members in your trust undertaking a joint/shared post within your system(s)?
FIGURE 18
- A lower proportion of respondents (29%) said they have board members undertaking joint/shared roles compared to 42% last year. 3% did not know.
- Members from acute specialist trust were most likely (44%) to say that they do have board members undertaking joint/shared posts within their systems.
- Members from London were most likely to say they have joint/shared posts (67%), and members from the Midlands were least likely to say they do (18%).
What is the reason your trust has established joint/shared board posts?
- The main reasons cited were support for collaboration, integration and partnership working, and financial saving, and many mentioned enabling knowledge-sharing.
“To enhance shared learning and collaborative working.”
Governance Lead, Combined Mental Health/Learning Disability and Community Trust
“To increase collaboration, reduce cost and increase multi skilled knowledge and involvement.”
Director of Corporate Affairs, Acute Trust
Please tell us which post and any notable challenges or benefits you feel this brings to your trust:
- Members provided several benefits of having board members undertaking joint/shared posts within their systems, the most common being shared expertise and financial benefits. Respondents also mentioned that duplication is minimised, decision-making capabilities are enhanced, and quality of care is improved. Members were less likely to provide challenges, but issues that were mentioned included workload and time constraints.
"Improvement in quality of care. We have also been able to leverage others shared experience and expertise which has proven to be more effective for service delivery, time and cost management.”
Governance Lead, Combined Mental Health/Learning Disability and Community Trust
“Several of our NEDs also sit on the board of a partner trust within our acute provider collaborative. There are practice workload and time constraints in serving on multiple boards.”
Governance Lead, Combined Acute and Community Trust
FIGURE 19
- A slightly lower proportion of respondents (39%) have a board member who is also a trust partner member on an ICB than in 2023 (42%). 3% did not know, lower than last year (8%).
- No ambulance trust respondent had a board member who is also a trust partner. Three quarters (74%) of combined acute and community trusts said they did not. Combined mental health/learning disability and community trusts were most likely to have a board member who is also a trust partner (67%).
- Those regions with higher than survey average representation on their ICB were: East of England (63%), London (58%), Midlands (55%) and South East (50%). Only 6% of respondents from the North West had a partner member.
Please tell us any notable challenges or benefits you feel this brings to your trust:
- The main benefits mentioned were improved communication with the ICB, being more influential on the ICB, and having direct involvement in discussions and decision-making. Some members also mentioned having greater representation of their sector. There were very few members who noted challenges; the most common challenge identified was time commitment. A risk of neglecting priorities within their own trust was highlighted by one respondent.
“The trust's provider perspective forms part of system discussions and strategic planning with direct reporting to the board.”
Company Secretary, Combined Acute and Community Trust
“The trust's provider perspective forms part of system discussions and strategic planning with direct reporting to the board.”
Company Secretary, Combined Acute and Community Trust
Other comments
Finally, is there anything else you would like to tell us about how system working is impacting your board and organisational governance, please do so here.
- In the final comments, many respondents said that system working has introduced additional time pressures and an increase in workload, with an added layer of complexity.
- Members also raised concerns over a lack of clear outcomes, as well as difficulty in understanding the strategic direction.
- Some said that there needs to be more of a focus on collaboration, consistency across ICBs, and relationships.
“System working is varied nationally as I have experienced and supporting a collective approach and sharing key best practice would be helpful. To increase understanding, reduce costs and increase effective collaboration.”
Director of Corporate Affairs, Acute Trust
“System working is taking a lot of executive and non-executive resource, which is already stretched to capacity and within the current financial context cannot be backfilled. It is crucial therefore that directors time is used effectively and that meetings have tangible outcomes - this is better in some areas than others.”
Company Secretary, Combined Acute and Community Trust
“The trust board receives very little input on systems partnership working. More work needs to be done collaboratively to benefit all partners.”
Company Secretary, Acute Trust
“It has doubled mine and others workload without tangible benefit. It erodes time for operational leadership and strategic thinking.”
Chair, Acute Trust