A dilemma for foundation trust governors

27 May 2021

Integrated care systems present an opportunity to expand the conversation so that local health policy is developed by local citizens – we should seize it.

The addition of integrated care systems to the worry list of foundation trust governors prompts the question – inspired by Tony Benn – to whom are you accountable and how can they get rid of you?

This is a multi-layered question if ever there was one that applies to several layers of the healthcare landscape.

At institution level the answer is straightforward: trust boards are accountable to the patients and service users and, in the case of an FT, the non-executive directors can be got rid of by the governors, otherwise it’s the regulator’s job. Executive directors are reliant on their chair and non-executives for their tenure.

At system level we do not yet know the answer and can only hope that the legislation will tell us – though there’s a real possibility that if the governance of ICSs is made up of directors from elsewhere, their accountability in terms of tenure might be wrapped up in those arrangements.

Lost in bureaucracy

Governor, NED and community involvement in ICSs could easily get lost in the maze of bureaucracy and faux governance so beloved of the NHS.

Governance is a means to an end but is not the end in itself. Governors hold non-executives to account for the performance of their board; non-executives are accountable, in legal terms, for the performance of the organisation. Both processes take place at the same time and are continuous – and for as long as services are planned, commissioned or provided, will carry on being necessary. What will change is the context in which they are planned and paid for.

Within that new context the voice of governors will need to be heard, both in continuing to hold their own organisations to account but also on the impact of wider plans. The draft legislation may say something about involvement of the wider public and being more ambitious on behalf of citizens would be a huge favour that governors could drive.

Elected public and patient/service user governors have direct links into the communities that elected them together with the deeper penetration many can offer through faith groups, and social and community connections.

However, while people generally feel strongly about their local hospital, finding ways of building enthusiasm for the remainder of the alphabet soup that comprises an ICS may be more challenging, which is a pity as one of the prizes to be won in the population health debate is to reduce reliance on the large acutes and redress the balance towards primary and public health provision.

Asking people what they want from the NHS may not deliver the answers you expect!

Expanding the conversation

So, why not extend and expand the conversation around ICSs to embrace citizens as a more broadly defined group? Taking councils of governors as the starting point and linking into their community networks, alongside primary care patient and public consultation groups, would give you the beginnings of something more expansive with a wide range of opinion.

Why don’t we foster greater civic renewal by inviting people to involve themselves in developing a local health policy that has been driven by local citizens’ views?

One of the most effective ways of collaborating is to try things out – engagement can foster co-production and unexpected successes. Any set of voices must include those of the clinicians – not as consultees but as the principal drivers of change.

What does seem possible is that if we don’t collaborate and make it as successful as possible on whatever scale, those who can will get rid of what stands in the way – whoever it is.

GGI’s recent guide for governors encourages as much participation in ICS development as possible. They are not to be stopped and going with the grain will help to develop solutions relevant to local communities.

Change should stimulate system involvement because the only point of making yet another set of changes within the NHS is to improve quality and outcomes for patients and service users.

There is something for us to seize here, an opportunity that has the potential to make a difference for everybody – so carpe system!


  • Wherever you sit in the accountability equation, the point is the quality of treatment and not the quality of governance.
  • As we move from institution to system it will be a missed opportunity not to expand the conversation so that local health policy is developed by local citizens.
  • Governors come from a community which is broad and deep. Accessing these will help to enrich the conversation.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk

Meet the author: Peter Allanson

Principal Consultant

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Prepared by GGI Development and Research LLP for the Good Governance Institute.

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