Neighbourhood health will not succeed on good intentions alone
Governance. It may not be the most glamorous subject, but without it, your ambitious plans will never get off the ground. Sewell Advisory’s Chief Executive Emma Bolton explores why neighbourhood health schemes need people who understand accountability and risk, and why these people are becoming harder to find.
The Government’s neighbourhood health framework sets out an important ambition.
It wants more care to happen closer to home. It wants services to work around people and communities, not around organisational boundaries. It wants primary care, community services, local authorities, voluntary organisations and wider public services to work together. That is the right ambition, building on what has gone before but looking to join it up more than ever.
Whilst the principles and vision are clear, the hard part is making it happen, especially in the face of some of the largest changes the NHS has faced since the Lansley reforms of 2013.
NHS England is being brought back into the Department of Health and Social Care, integrated care boards are being asked to significantly reduce running costs, and many organisations are reshaping, reducing or redesigning their corporate and commissioning functions. The King’s Fund has described the changes to ICBs as a potentially “seismic shift”, with significant implications for commissioning, assurance, performance management and local system working.
This matters because transformation does not happen by itself.
It needs people who understand governance, accountability, risk, assurance, estates, programme delivery and the practical realities of working across complex NHS systems.
Those people are becoming harder to find and are increasingly spread across fragmented parts of the new system. There is a risk that, in the drive to reduce bureaucracy, the NHS also loses some of the skills that help make change deliverable.
These are specialist skills. They help organisations make good decisions, manage risk, spend public money well and turn strategy into action.
The NHS is being asked to shift care from hospital to community, make better use of digital technology, focus more on prevention, deliver neighbourhood health, reduce costs, improve productivity and make better use of its estate. The Government’s 2025 mandate to NHS England set out these major shifts, including moving care from hospital to community and from sickness to prevention.
But at the same time, many of the people who understand how to govern and deliver that kind of change are under pressure, moving roles, leaving organisations or being lost through redundancy. That creates a real delivery risk. In my experience, public sector transformation rarely fails because people do not care enough. I’ve spent the majority of my career leading NHS teams across a range of organisations and I’ve always worked with people who have devoted their careers, and lives, to making a difference for people who really need it. Transformation fails because it lacks the practical arrangements needed to drive it. That means governance.
And while governance is not always the most exciting word, it is often the difference between a good idea and real improvement.
Good governance helps people understand who is responsible for what and has the authority to make decisions, how risks are managed, how progress is measured, where issues go when they can’t be solved locally, and how leaders know whether things are really working.
It allows decisions to be tracked and evidence-based, and helps us know whether our outcomes have achieved the results they set out to deliver.
Neighbourhood health will involve lots of different organisations, professions and teams. That makes strong governance even more important, not less.
The risk is that everyone is involved, but no one is clearly accountable
Integrated neighbourhood teams will bring together people from different parts of the system. That is a huge opportunity, but in a system where organisations have different budgets, pressures, priorities, cultures and reporting routes, working things through properly is essential.
The danger is that everyone is around the table, but nobody is completely clear about who owns the decision, the risk or the outcome. Overlay that with reorganisation and restructuring, and people changing roles. Teams are reduced. Decision-making routes move. Corporate memory is lost. Informal relationships break down. Structures that once made sense no longer fit the new environment.
The BMJ has reported concerns that cuts to ICBs could weaken local commissioning expertise and lead to a loss of corporate and expert commissioning memory.3 This is important, because neighbourhood health will depend on exactly that kind of memory and expertise.
It will need people who understand:
- how NHS organisations really make decisions
- how boards and committees work
- how assurance should flow
- how risks need to be escalated
- how estates, workforce, digital, finance and service planning connect
- how to manage complex partnerships
- how to keep delivery moving when organisational boundaries get in the way
These are skills that are built through experience, and once they are lost, they are difficult to replace.
What we see in our work
At Sewell Advisory, we regularly carry out reviews across different parts of the NHS and public sector, considering operating models and governance arrangements. We have undertaken this work across a breadth of functions, drawing on ‘well-led’ principles. What we have seen are very similar underlying issues.
Accountability has become blurred over time, with reporting giving information but not real assurance. Decision-making routes are often not clear, with committed and capable teams who are also working within unclear structures, and with operational pressures crowding out longer-term thinking, Contracts, boards and committees exist, but don’t always support delivery, and performance measures don’t properly reflect what matters.
We have successfully demonstrated that, by considering system maturity and putting action plans and governance arrangements in place, we can develop structures and processes that underpin success.
That is why independent review and practical governance support can be so valuable. Sometimes organisations need an external view to refresh things where the system has become too complicated, too slow or too unclear. At other times, a new project or challenge needs an external perspective and insight to ensure that it gets off to the right start.
If you’re asking:
- Is our governance fit for what we are trying to deliver?
- Are we clear who is accountable?
- Do our reports tell us what we need to know?
- Are our risks being managed or just listed?
- Do our boards and committees support delivery?
- Are our neighbourhood, place and system arrangements aligned?
- Do we have the right programme structure to deliver change?
- Are estates, workforce, digital and service plans properly connected?
…then you may benefit from an external review of your governance, to find out if it’s helping delivery, or just getting in the way. An independent perspective can challenge your preconceptions, bring in practical experience and help you focus on making change deliverable. This can determine whether neighbourhood health moves from national ambition to local reality.
Neighbourhood health is a major opportunity to improve care and make services work better for local people. It will not succeed on good intentions alone. It will need clear accountability, strong governance, practical programme management and honest reporting.
And it will need people who understand how complex NHS systems really work.
At a time when the NHS is being reorganised and important skills are being lost, that expertise should not be taken for granted.
Because strategy may set the direction. But governance is what helps people get there.
Are you looking for support on governance for your neighbourhood health project? Find out more about how we can help.