John Wilderspin on the use of peer challenge to develop shared systems leadership across the NHS and local government

After 25 years of competing within an internal market, NHS organisations are having to get to grips with a world where success is increasingly measured by your ability to collaborate, and to form effective partnerships across complex local systems. One sector which has long experience of developing effective partnerships is local government, in part because local government can only succeed by building constructive alliances with others.

This doesn’t just apply to the building of partnerships at a local level; the whole way that local government does development and improvement is by working collaboratively with other councils in what is termed “sector led improvement”. At the heart of this approach is a peer review, or more accurately a “peer challenge” process.

The peer challenge process can also benefit collaboration in other contexts where productive relationships will be equally critical

“Peer challenge” involves a team of peers from other parts of the country spending time with an individual local authority, “running the rule” over the way they operate.

Constructive challenge from a group of people who really understand your business is a great way to identify areas for improvement, and to help you think through how to fix them. This applies particularly to the intangible, but crucial issue of relationships, given how important productive relationships are to the successful running of a council.

By extension, the peer challenge process can also benefit collaboration in other contexts where productive relationships will be equally critical. This is why the Local Government Association and NHS Clinical Commissioners, working with NHS England, NHS Improvement, Public Health England and a range of other stakeholders have developed a peer challenge process specifically for whole Health and Care systems.

The process has been piloted recently, and I was one of the peers who took part in the pilot process in Coventry and Warwickshire.

Although Coventry and Warwickshire are incorporated into one sustainability and transformation partnership footprint, and some NHS organisations cover the whole patch, in local government terms it is made up of two very different local authorities (Coventry City, a unitary authority, and Warwickshire, a two tier county council).

Working together

Politically, Coventry is Labour controlled, whereas Warwickshire is Conservative controlled, but it is inspite of these political differences, both councils recognise the importance of working together where it is to the advantage of their two populations.

Peer challenge is a very practical way of delivering support; it is based on a tried and tested approach from another part of the public sector

The peer challenge team was drawn from across the country, and from a variety of backgrounds, both NHS and local government, as well as two LGA colleagues with wide experience of the peer challenge process. We spent three days on site, and over the course of that time spoke to over 50 people from across the health and care system.

This included NHS chief executives and chairs, GP leaders, NHS England, Healthwatch, as well as political leaders and officers from the two local councils, and a range of local partner organisations. The chairs of the two local health and wellbeing boards as the local “sponsors” of the process had set out a number of areas for us to focus on, but once we started our interviews, the focus of the discussion became more self selecting.

Overwhelmingly, the main issue that people wanted to talk about was the STP. Sometimes the issues which were surfaced were substantive, for example how to align objectives across different governance processes, but the bulk of the discussions were about relationships, and how to make them conducive to effective joint working. So how can the peer challenge process help to nurture, or reinforce, the development of productive relationships?

Firstly, it provides a “safe space” for local leaders to discuss the challenges that exist within their system with peers who have faced similar issues. Peer challenge is not a judgement process; there is no pass or fail, and the peer reviewers all have experience of the inherent challenge of managing complex relationships in a highly pressured environment.

They can also offer impartial advice on how to untangle difficult situations, acting as an “honest broker” where things have got stuck. Crucially, their role is to act as a “critical friend”; they can challenge people in the system who are behaving poorly or avoiding their collective responsibility, without it being seen as a personal attack.

Having now participated in a system “peer challenge”, I firmly believe that it could be a very valuable way to support the implementation of STPs, and the other collaborative processes with which the NHS is now engaging. Effective collaboration cannot be performance managed or regulated into existence, but it can be fostered and accelerated by well designed support.

Peer challenge is a very practical way of delivering that support; it is based on a tried and tested approach from another part of the public sector, which has been adapted specifically to meet the needs of the moment. I hope that people will follow the example of Coventry and Warwickshire, and try the process out for themselves.