All change or no change – governors and systems

17 February 2021

NHS foundation trusts are required to develop a membership of people reflecting the communities they serve. In turn, these members elect the majority of members of the Council of Governors (some others are nominated by commissioners, local authorities and academic partners). Their role is to hold non-executive directors to account for the performance of the board and to represent the interests of the members of the trust and the public.

There is a difference between accountability and holding to account. Those accountable within the trust are responsible for delivering an outcome, can expect to be asked to explain or justify their actions and so be judged. For governors, holding to account involves receiving an account of actions taken and possibly further explanation or justification.

They are then entitled to test the account by asking questions to come to a view on whether actions are correct, reasonable, justifiable in the circumstances or extensive enough – and to give feedback. Accountability and holding to account are continuous processes. Provoking challenge and diversity of thought offers a way of avoiding ‘group think’ in decision-takers.

Delivery of care to patients and the way it is planned and paid for is changing. Last week’s white paper makes it clear that integrated care systems will be put onto a statutory footing with two boards: an ICS NHS board responsible for creating a local health needs plan and system-wide capital plan and securing provision, and an ICS health and care partnership board responsible for drawing up a wider health and public health and social care needs plan, which the ICS NHS board and local authorities must take into account when making decisions.

Providers will become part of a local collaborative but at the same time remain accountable for their current responsibilities. Does this mark the end of any provider influence? We think not. There will be changes: foundation trust (FT) ‘ownership’ of capital will end and their plans will be part of system-wide arrangements. And in a gesture towards diluting the duty laid on FT directors to act to promote the success of their organisation, FTs will be permitted to form joint committees with other providers and participants and be authorised to deal with delegated decisions. But in a planned economy providers remain central to both local and specialised commissioning as well as delivering services, as does the role of governors holding them to account.

Run with change, don’t subvert it

Change is coming and working out how to run with it is more positive than looking for ways to subvert it. Thinking needs to move away from the institution itself to its role in delivery across the system. In other words, from something defensive to something much more outcome-focused and seizing the opportunity to develop proactive focus on preventative health and deepening links into the community, primary care and education.

Delivering across a local geography should provoke thinking about each constituent’s contribution. Being concerned for the population as a whole and as far as systems are concerned consulting people about change remains an obligation and not an option. Governors should encourage ICSs to talk openly to the people they serve and help this to happen, perhaps by encouraging the establishment of engagement forums as well as formal consultations.

As a governor you have a duty to advise your own provider on its plans and should expect to do the same within the system even if this is not yet centrally mandated or even described. This is the way to ensure that finances work properly, investment continues and your trust can flourish.

Reviewing how plans are put into practice to a high quality forms the centre of your being able to hold your trust to account. As part of a system plans will look beyond a single institution. To make system working a reality things cannot stay as they are; ensuring they don’t will be a valuable service.

Quality matters

Quality matters will also loom large. Staff governors in particular should be asking about the impact of collaboration on the people in the trust; is the balance between change and continuity and how it affects staff being talked about and concerns addressed?

Other issues for governors include:

  • Helping their trust to play a full part in the local system – perhaps even encouraging it to be the lead or anchor institution – while retaining its own individual character.
  • Are non-executive directors locked into overseeing what the system is doing?
  • Is risk a key ingredient of ICS agendas?
  • Adjusting their mindset to focus on overall outcomes across the system because these are likely to bring with them changes to pathways and therefore what patients experience.

Overall, governors are now being asked to think more broadly from the point of view of a local citizen or patient outside the confines of their hospital trust.

Keeping close to the board, constituents and fellow governors in other trusts is essential and insisting on having a way to express views should be as important to the system’s leadership as to your own trust – and should be a hallmark of full collaboration.


  • The structures and delivery of services in the NHS are changing but the fundamentals of holding to account by foundation trust governors remain.
  • It’s even more important that governors test ICS plans through the lens of their organisation.
  • But the best way to be critical is to be positive – moving mindsets to embrace place and running with the grain of change will be in the best interests of individual trusts and the integrated system overall.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email

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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