Embedding the conditions for successful care collaboration

The recent decisions in Torbay and several Welsh councils, including Newport and Monmouthshire, to unwind longstanding health and care partnerships will undoubtedly reignite debate about whether integration really works.There are plenty of people who concluded years ago that pooled budgets are too risky. Others argue that delegated arrangements contain inherent weaknesses around accountability, financial risk and benefits realisation. These latest setbacks will prompt yet more discussion about organisational design, governance models and structures.After 25 years of working across public-purpose organisations, I have reached a different conclusion. It is not the principle of integration that is failing. It is the way we have applied it.The real problem is that we still have not learned how to treat system working as a serious, investable and sustainable public-sector capability. Simply repeating the word ‘system' does not make one exist.What is striking about the recent cases is how similar the underlying themes are. In Wales, reviews highlighted uneven funding arrangements and governance weaknesses that left organisations carrying financial exposure without corresponding control. In Torbay, concerns focused on accountability, governance and the allocation of risk.These are not signs that collaboration is impossible, they are signs of system immaturity. For decades, political leaders, policy-makers and practitioners have championed integration. Entire reform programmes have been built around concepts such as partnership, place leadership and system working. Integrated Care Boards are only the latest manifestation of that ambition.Yet, beneath the rhetoric, these ideas often remain underdeveloped. That is not because leaders lack commitment. Across local government and the NHS, countless individuals devote enormous energy to building relationships, navigating different cultures, balancing competing priorities and creating genuinely joined-up services.The problem is much more institutional.We do not systematically develop system leadership.We do not consistently invest in cross-organisational governance capability. We do not reward collaborative outcomes to the same extent that we reward organisational performance. Most importantly, we rarely define what mature system stewardship actually looks like, let alone develop it deliberately. In truth, partnership working is still often treated as something that happens alongside the real business of organisations, rather than as a discipline in its own right.The consequences are predictable. When financial pressures intensify, organisations retreat to what they can directly control. When accountability becomes unclear, they seek certainty. When demand rises, statutory responsibilities and organisational budgets naturally take precedence.This should not surprise anyone. Imagine expecting a finance function to succeed without professional standards, clear accountabilities, investment in capability and robust processes. We would never accept that in any other critical area of organisational life. Yet this is often how we approach integration.We ask partnerships to address some of society's most complex challenges while operating within governance frameworks that remain largely organisational, funding mechanisms that remain largely institutional and accountability arrangements that continue to reinforce separation rather than collaboration.This is why debates about organisational form miss the point. Delegated arrangements can work. Pooled budgets can work. Alliance models can work.Equally, all of them can fail. The determining factor is usually not the structure itself, but the maturity of the system surrounding it.The lesson from Torbay and Wales is therefore not that integration has reached its limits. It is that, after more than two decades of talking about collaboration, we still have not embedded the capabilities, incentives and governance needed to make it routine.The question is whether governments and institutions are finally prepared to invest in system working with the same seriousness that frontline leaders have demonstrated for years.Until they do, we should be less surprised when partnerships struggle and more impressed by those that succeed despite the conditions created around them. Aidan Rave is partner and principal consultant at the Good Governance Institute

Title

HEALTH AND CARE INTEGRATION

Embedding the conditions for successful care collaboration

By Aidan Rave | 06 August 2026

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