Effective governance between partner organisations is essential to safeguard each party's reputation, say Bryan Stoten and colleagues

It is four years since the Integrated Governance debate paper was published by the NHS Confederation. Most NHS organisations in England will by now have reformed their internal governance structures and board effectiveness, especially those aspiring to be foundation trusts. But in our increasingly pluralistic world, just how good is the governance between organisations?

The Healthcare Commission recently reported in relation to service failure (in Learning from Investigations ) that "problems often occur at the borders between one organisation or team and another". And in Governing Partnerships , the Audit Commission made clear that "in the absence of formal governance arrangements, responsibility for supporting the governance of partnerships falls to partners' own corporate governance mechanisms".

Industry recognises the increasing likelihood of even well governed organisations' reputations being put at risk by the actions of their suppliers or partners. The latest Economist Intelligence Unit review of strategic risks found it is now the highest-ranking priority (52 per cent) above regulatory (41 per cent) and human capital (41 per cent) risks. Over 60 per cent of companies interviewed also stated that reputational risk was the most difficult risk to manage.

It is perhaps timely then that Integrated Governance authors John Bullivant and Michael Deighan have turned their attention to governance between organisations. A series of workshops and field tests initiated by the Department of Health through the NHS Clinical Governance Support Team and more recently supported by the Institute of Healthcare Management and consultant Frontline has led to a debate paper by Dr Bullivant and Professor Deighan. Supported by NHS Confederation chair Professor Bryan Stoten, the confederation will shortly be sending it out to all members.

The paper presents the premise that: "In our complex world, we cannot operate without the support of others, but partnerships and other relationships bring risks as well as opportunities to both service delivery and our reputation. We must manage these but our board must also seek assurance that risks to our strategic objectives have been identified by our partners with adequate controls in place."

Extend your reach

This appears, like the Audit Commission statement, to suggest that corporate entities such as primary care and trusts must extend their reach, their risk registers and assurance frameworks to the activities of others. Not only must they manage these arrangements, but boards have a responsibility to gain assurance that the systems and processes are good enough not to compromise their patients' safety or their organisation's reputation.

This topic was highlighted by NHS finance, performance and operations director general David Flory at the December 2007 Healthcare Financial Management Association conference. He made it clear that there is a "whole field of decisions being made completely out of the context of what patients really need and how we best need to work together across organisational boundaries to support the best deal for patients and to support them in getting their care when they need it, where they need it and to the right quality".

He continued: "We have a collective responsibility to ensure that organisational boundaries are not allowed to get in the way of joining up services for patients.

"The reputational damage of getting these things wrong spreads far and wide. It affects us all; it really focuses on the organisation concerned but it damages the service."

The work on governance between organisations has identified three levels of concern. First, at patient level, inter-organisational failure in continuity of care can compromise patient safety and comfort. Second, at the partnership level, there is a need for greater clarity and effort to ensure the strategic partnerships work and managers at the interface are both encouraged and held to account. Third, there is a meta level of mutual aid where, despite recent efforts to develop resilience forums to co-ordinate planning for all major threats, including pandemic influenza at regional and local level, there are real concerns as to whether there is the commitment to act. Underpinning all three levels is the need to reinforce mechanisms for assurance.

Professor Deighan says: "We have tried to be very practical in our approach, identifying with the help of regulators the common themes where boundary failures occur, then searching for better practice examples that highlight the simple rules of good governance."

The team will produce a series of between-organisation governance assurance prompts for board directors similar to those produced for internal governance in England in 2004 and Northern Ireland in 2007. Professor Deighan says these will assist health, local government and independent providers and suppliers to tackle the tricky issues by asking the right questions.

Other supports include a maturity matrix to allow boards to determine their capacity to handle the issues and a series of scenarios which boards can work through to practise how they would handle reputational risk.

Professor Stoten introduces the debate paper thus: "Our current complex and pluralistic world of health and social care requires better partnership arrangements than ever before. Boundary management and boundary bridging can now only work if it takes into account local history, culture and immediate imperatives. This requires, in [NHS chief executive] David Nicholson's phrase, looking out not up."

The requirement - even duty - to partner with good management and good governance between organisations may be enunciated centrally, but it will only work through local engagement and determination. The debate paper will be available early in April.