There is no legal form, structure or system that can completely inoculate organisations against failure, whether at local or system level. This is because they are led by people and, as in any industry, success is contingent on the cumulative behaviour of individuals. However, good corporate governance provides a vehicle for the provision of sound leadership, clear direction and dynamic accountability.

All available evidence suggests long term success is unlikely in the extreme in organisations where good governance is lacking. The unitary board model provides a better prospect of good governance than any other model of leadership and direction. It provides a forum to set and model positive values and behaviours. The duty on non-executive and executive directors alike to challenge means that strategy is thoroughly tested and vetted. It provides a mechanism by which executive directors can be supervised effectively and be challenged on the results they deliver and it provides a key line of defence in the successful management of risk.

Strong board leadership with sound local accountability need to be key components of system working and the future evolution of systems. That either means leaving accountability in local organisations as it is now, or developing a more radical vision of how health and care can be delivered and placing system working itself on a firmer, board led, footing.