Non-executive directors and integrated care systems: What good looks like

Key points

• Provider trust chairs, non-executive directors and CCG lay members (NEDs) have played a vital leadership role in ensuring NHS boards act in the best interests of patients and the public. 
• Despite a real appetite among provider and commissioner NEDs to be more involved and make a meaningful contribution to systems, many do not yet feel fully engaged in systems.
• The NHS Confederation believes constructive NED relationships throughout a system is mutually beneficial, and achievable, with or without legislation and guidance.
• This report shares examples of where NEDs have successfully engaged with their systems and integrated their independent voice.

Introduction

The independent voice has long been a crucial part of the NHS structure. Provider trust chairs, non-executive directors and CCG lay members (here we will refer to all as ‘NEDs’) have played a vital leadership role in ensuring NHS boards act in the best interests of patients and the public. NEDs bring different perspectives and provide constructive challenge from a strategic viewpoint. They are able to focus on building relationships for the long term on a foundation of good governance, challenge, trust, collaboration and confidence.

As the legislative process surrounding integrated care systems progresses, and further guidance is published, we start to see how the context in which NEDs will work is changing. We now know that each ICS board will be required to have a minimum of two independent NEDs who will not normally have another role within that system. Although the NED role seems to be considered essential in the ICS Design Framework, the HR Framework for Developing Integrated Care Boards, published in August 2021, clarified that board-level colleagues, including NEDs, are not considered in the employment commitment and will therefore not be directly transferred into the newly established ICS body. Consequently there is a risk that skills, knowledge and experience are lost.

While many leaders in our ICS Network support the idea of independent NEDs on the integrated care board, others felt that NEDs who are also part of provider organisations can offer better scrutiny, as they may better understand the context of certain decisions. To recognise the valid concerns that systems have on this issue either way, there was agreement that flexibility must be built into IC board development to allow for different NED arrangements, depending on what works for each system. 

However, a recent NHS Confed survey showed that despite a real appetite among provider and commissioner NEDs to be more involved and make a meaningful contribution to systems, they did not yet feel fully engaged in systems.

This report shares examples from NEDs of what has worked in their systems to engage and integrate their independent voice.

NHS Confederation viewpoint

Constructive NED relationships throughout a system is mutually beneficial, and achievable, with or without legislation and guidance. Independent and diverse voices will be essential for accountability and risk management, to ensure appropriate challenge and diverse perspectives. Regardless of arrangements for IC board NEDs, it would be wise for ICSs to engage their provider NEDs and for consideration to be given to the role of NEDs at place level.

The Surrey Heartlands NEDs discussion forum

"The phrase ‘partnership working moves at the speed of trust’ is very resonant to NEDs in Surrey Heartlands.”

The introduction of STPs in early 2016 and the requirement for local health systems to work together to develop sustainable transformation plans helped to break down barriers across the system, including for the NED community within Surrey Heartlands Health and Care Partnership ICS. As part of the initial development of a Surrey STP, lay members and NEDs were invited to several all-partner days. This informal environment meant ideas and views could be exchanged more easily and the approach helped foster cross-partner relationships and trust between individuals.

Jonathan Perkins, CCG lay member and deputy chair of the forum, said: “As NEDs, we felt that our input could be harnessed more effectively if we met as a group and pooled our experience to work together. So, the NED Discussion Forum was formed to discuss matters of common interest, to help build relationships within the system and to help Surrey Heartlands take a strategic view.”

The purposes of the forum are:

1. to continue to foster trust and collaborative working relationships between NEDs, lay members and council members
2. to provide the opportunity to discuss topics of common interest relating to Surrey Heartlands
3. to provide advice and views from members’ perspectives to the leadership of Surrey Heartlands
4. to support the objectives and values of Surrey Heartlands.

The forum has around 70 members, including:

• lay members and the independent nurse of the CCG
• two system NEDs
• all chairs and NEDs of provider trusts and other provider organisations
• Surrey county councillors
• members of Healthwatch, who have an open invitation to attend.

The senior responsible officer of the ICS and other senior system executives are copied into all the agendas, minutes and papers for the NED forum, but are attendees only by invitation.

The forum has also contributed in a number of specific areas:

1. Discussions on citizen engagement, wider determinants of health, health inequalities, prevention and public health, system risk/system risk appetite and the strategic direction of the ICS.
2. Governance arrangements of the ICS as it has developed and matured, including the role of non-executives within its structures.
3.  Since its inception, the NED forum has made in-depth comments on the consultation that led to the white paper, and its members have formed the nucleus of a governance working group looking at the necessary changes the white paper proposals will have in Surrey Heartlands.

Due to the success of the forum, the ICS executive asked that individual members sit on all of the working groups within the ICS, focused on the operational planning priorities for the financial year.

“The principal value of the NED forum has be the breaking down of barriers between organisations and the increased sense of collaboration between NEDs across the system. The phrase ‘partnership working moves at the speed of trust’ is very resonant to NEDs in Surrey Heartlands.” Jonathan Perkins, CCG lay member and deputy chair of the forum.

Lincolnshire system NEDS forums

"As a group of non-executive directors we can shape the system strategy and approach to service improvement, provide a broader perspective to key issues, and contribute to strengthening the decision-making process."

In Lincolnshire, quarterly forums are held for non-executive directors from all Lincolnshire Health organisations, both from provider trusts and the CCG. The forums were introduced to improve relationships and understanding across partners in the local health system. The sessions are always well attended, with positive feedback from participants about the value they add to the overall governance arrangements of the Lincolnshire system.

Hosted by the chairs of the participating organisations, and attended by respective chief executives/ICS leads, and other system responsible officers, the sessions are wide-ranging, focusing on the key issues that relate to the development, planning and delivery of services across the county of Lincolnshire.

The content of the sessions varies according to identified need, but has included:

• specific briefing items to improve knowledge or share learning
• exploration of key issues such as system workforce and financial challenges
• oversight, stewardship and assurance on system submissions such as the NHS Long Term Plan and the acute services review
• establishment of a system-wide governance framework
• opportunities for executive colleagues working in system roles to test current thinking on key issues, to seek feedback and to inform future developments.

The benefit of these sessions stems from the opportunity for the participants to share views in a collaborative forum. Based on a collective intent to improve the health outcomes for the population, the agenda enables inclusive conversations that people enjoy and feel able to make a contribution to. In addition to bringing their organisational perspective to the conversation, the debate is further enriched by the individual experience and skill set that all NEDs bring to the board table.

"By working in this way we have found that as a group of non-executive directors we can shape the system strategy and approach to service improvement, provide a broader perspective to key issues, and contribute to strengthening the decision-making process. It also adds value to our internal board discussions as we have a wider understanding of the operating context and perspectives of partner organisations.” Elaine Baylis, chair of United Lincolnshire Hospitals and Lincolnshire Community Health Services and interim chair of Lincolnshire ICS.

The PCN/neighbourhood level independent voice in a system  - Darlington PCN

“A strong NED should, at place level, have the ability to do the usual stuff but also be a portal to fresh networks.”

Chris McEwan is the lay member for Darlington PCN, which covers 11 GP practices and over 108,000 patients.  He believes that building relationships is crucial. A well-known figure in the community through decades of public service, including as a local councillor and lead for a number of service areas, Chris is able to quickly forge strong and enduring relationships. This has stood him in good stead as he works to promote the work of the PCN. His role as PCN lay member is to both give external challenge and perspective, but also to actively support engagement with the wider community.

Chris has helped the PCN to look outwards and to start to make connections with civic society, including the local authority and the police service. By establishing regular meetings with senior figures in these organisations, Chris has been able to establish the PCN as a key player at place level.

Working at place level is, for Chris, particularly important: “There needs to be respect for place, as often the people working here are ’in the trenches.’ If systems (ICS) are to work, there needs to be action and delivery at place level. This will require strong connections and networks with communities, be they geographic or demographic or other.”

Chris has harnessed social media to further engage the community and develop the role of the PCN. He believes this works best as a tool not a hobby and that it’s important to learn what works and to bring in experience and ideas. The PCN has an active Facebook and Twitter presence.

However the job is not yet done. Although Chris is in regular communication with the chair of the local foundation trust, he is keen to start to build connections within the rest of the system, including the NEDs of the local trust, the CCG lay members, the ICS NEDs once in post, and the wider system leadership. This will enable the PCN to have a strong voice within the system and represent the local community in decision-making.

Chris believes that place has the ability to progress action on health inequalities not just through data but also through dialogue and engagement at a real level.  Place has the ability to develop relationships with those within a locality who have a shared mission to improve civic society.

“A strong NED should, at place level, have the ability to do the usual stuff but also be a portal to fresh networks,” says Chris.

How the NHS Confederation can support you

The NHS Confederation has a range of support available for NEDs:

• A monthly newsletter
• A non-executive leaders network
• A FutureNHS platform to support communication and sharing experiences
• The NHS Reset monthly chairs and NEDs meeting
• Webinars and engagement events 
• Local workshops to support your system with NED and lay member engagement
• Taskforce on increasing NED diversity.

We also have briefings on key publications relevant to NEDs and system working:

• ICS Design Framework
• Integrated Care Partnership Engagement Document
• What the NHS White Paper Means for the Future of Health and Care in England
• The Health and Care Bill
• The HR Framework for Developing Integrated Care Boards
• Strengthening NHS Board Diversity