System Governance as a Pillar of Integrated Care

February 13, 2026

Introduction

The International Foundation for Integrated Care (IFIC) hosted a Forum discussion in December 2025, bringing together five panellists who are experts in integrated care from England, Ireland, Canada, Australia and Spain to share their experience of changing governance in the context of integrated care.

Photos of the speakers at the system governance forum - Áine Carroll, Anne Wojtak, Arturo Alvarez-Rosete, Carmen Huckel-Schneider, and Mark Golledge.

Governance is one of the Nine Pillars of Integrated Care. IFIC first published the Nine Pillars in 2020¹ and has spent the last 18 months revising and validating an updated version. Governance, alongside leadership, is a key mechanism for sharing accountability for integrated care. Through these interdependent mechanisms, people and organisations share accountability at the local and system level to deliver the shared purpose for integrated care, ensuring that decisions are made collectively, action is taken collectively and aligned with the goals of people and communities.

Systems in different countries are trying to balance delegation for local autonomy and accountability against central control for performance management. We know that system governance is an important enabler, and when it is not fit for purpose, a constraint, to integrating care. In our discussion, we explored the factors at play in different systems; the nature of the national debates on the topic now and the evidence informing that debate, and what we are learning from practice about what works and doesn’t in getting the governance balance right between centralisation and local devolution for population health.

What is needed now is genuinely integrated governance which enacts the collaboration and demonstrates the trust that system actors often talk about but don’t consistently act in accordance with. The themes that emerged from our discussion point to the challenges but also the solutions that will help us make this a lived experience.

Challenges

THE GOVERNANCE CHALLENGES ARE SIMILAR IN THE FIVE COUNTRIES

There is a very real tension between centralisation and local autonomy

Across all jurisdictions, there's a fundamental struggle between central government oversight and local system flexibility. In England, the concept of "earned autonomy" for providers reflects this tension, while the plan to streamline NHS England into the Department of Health and Social Care signals recentralisation. However, the last couple of years has seen a shift away from commissioner-provider splits toward integrated care systems where it's much more about relationships and shared accountability for population health.

In Ontario, Canada, the government initially supported Ontario Health Teams (OHTs) to choose their own priority areas of focus but recently mandated them to focus on primary care attachment, illustrating how ministerial commitments may be in tension with local priorities or interests. Ireland is transitioning from a nationally centralised HSE to six health regions, representing the most significant redistribution of authority in Irish healthcare in decades. This reform has the potential to fundamentally reshape how care is planned and delivered for populations, but only if decision-making authority, resources, and accountability are meaningfully aligned at regional level.

In Australia, the collaborative commissioning initiative trialled in New South Wales is a mechanism through which tensions might be resolved and required forming joint committees between the executives of hospital networks, as well as primary care networks. Evaluation of the collaborative commissioning initiative revealed that top-down contracting delivered less impact than locally sensitive strategic commissioning where regional partners examine information closely together to identify gaps.

There remains a governance maturity gap that doesn’t support ambitious integrated care strategy implementation

Our panellists emphasised that people in systems are very good at writing strategies that acknowledge complexity but struggle with the work of governing complexity. Instead, policy makers often strive to “manage” complexity by designing top-down governance structures. Ireland was described as having a governance maturity deficit rather than lacking strategy. To cite Schulmann et al, “governance deficiencies and conflicting policy visions can engender discordance, uncertainty, and distrust at a time when they are most needed”². Ireland's regional reform contains strong statements of principle - subsidiarity, autonomy, population-based planning - but leadership becomes rhetoric if authority does not follow responsibilities. In Spain, a white paper published in 2011 contained 63 recommendations for integrated care but came with no funding and "was quickly forgotten."

This gap is evidenced in the gravitational pull of organisational governance over system governance

A persistent challenge is moving from organisational self-interest to system-level thinking. In Ontario, OHTs have different local partners involved in governance, and silos between partners and sectors, as well as power dynamics, may impact the ability to advance system governance and ensure partners act in the best interest of the community. This underscores the importance of bringing the leaders and governing boards of individual organisations into the discussion early on to understand the risk and fiduciary responsibility that they have, not only to their own organisation, but to the system.

This challenge, viewed from the point of view of so-called system leaders, can create problematic dynamics. In the case of Ireland's reforms, health system reorganisations have repeatedly created system leaders who are responsible but not authorised, accountable but not empowered, and visible but unable to act, effectively positioning them as risk managers rather than system builders. This dynamic actively undermines the relational leadership required for integrated care. In Spain, this is seen in terms of accountability as the sole responsibility of managers at the top with little or no horizontal accountability between providers.

There was consensus across the panellists that when governance seeks to control what it should instead support, leaders retreat into compliance, caution, silo preservation, and blame avoidance, and integration becomes performative rather than transformational.

Solutions

THE SOLUTIONS TO OF THESE CHALLENGES ARE LOCAL AND GLOBAL

Trust and relationships are a foundation for system governance

Governance for integrated care relies heavily on willingness and trust for collaboration and works well when you have had time to build collaborative relationships over years. As shared in the case of England, it's much harder when those relationships don't yet exist. In Gloucestershire, provider organisations are members of joint boards, which include the local authority, healthcare providers, general practice and primary care, who have been working collaboratively together for several years. Ontario emphasised that in most cases partners have agreed on a common shared purpose and vision, and some core behaviours or values that everybody has signed on to, which includes holding each other to account for acting in the best interest of the community, not your organization. Only when this is well established can systems move together to make some of the difficult decisions about reallocating and sharing resources for integration including realigning payment mechanisms, a core governance responsibility in the sense of stewardship or the responsibility of protecting and sustainably using resources for the future benefit of the health and well-being of society.

Role of Structures and Recent Innovations

While relationships matter, structures provide necessary protection. Spain recently saw a significant development: on November 26th, Catalonia passed a law creating an integrated health and social care agency. The law includes a sentence that refers to how the agency needs to operate within a decentralised approach, and with territorial proximity, and with the participation of the people at the centre of care. This illustrates how central initiatives are not necessarily negative, but they can help to reinforce the quest for integrated care.

But there was a note of caution about rushing to formalise structures too early before trust and relationships are well established. Ontario experienced significant pushback when attempting to formalise governance without clarifying the role and relationships to partner boards. About two years ago, the government proposed requiring OHTs to set up not-for-profit corporations with a board of directors; however, due to significant reaction, primarily from hospitals, but other partners as well, the government withdrew the proposed legislation.

Neighbourhood or local models of integrated care that involve the local population in co-creation and governance

Several jurisdictions are focusing on neighbourhood-level integration. England is implementing neighbourhood models of care. In Gloucestershire, they have sixteen neighbourhoods (within six localities spanning the Gloucestershire County) bringing together multi-disciplinary teams and using local community assets to respond to the health and care needs of the local population. England is also planning to shift funding proportions, to community-based care from hospitals. In Gloucestershire roughly half of NHS funding goes to the acute sector. The role of system governance will be to shift some of that proportion of funding over time so there is much greater focus on prevention, an issue of particular relevance in Ireland as regions are expected to take responsibility for population health outcomes without yet having full financial or commissioning levers. Our panellists all shared the view that deep and meaningful community involvement in local governance is essential to move past the “consultation” approach that too often focuses on quality issues, such as if the room is clean, the size of the room, if it has a toilet, rather than on how the person perceives and experiences care.

Recognise that governance reform is not a technical process but a political one

Tackling governance is inherently political. Spain's experience shows that even though power was transferred to regions, many autonomous communities copied the old central model instead of redesigning it. Despite decentralising to 17 autonomous regions, many regions have centralised internally—reproducing centralised structures at the regional rather than national level. The decisions that need to be made to make the shift from central command and control to local autonomy and from organisational governance to system governance require supportive infrastructure and arrangements (the technical part) but also courage and belief that integration is the right and value-based thing to do in the face of opposition (the political part).

A new governance theory that might help guide solutions

Áine introduced the concept of adaptive relational governance as a new theoretical framework. This approach argues that governance succeeds not when it eliminates uncertainty, but when it embraces uncertainty, makes uncertainty discussable, shares responsibility and makes learning visible, and authority legitimate through trust.

The central question shifts from "are we in control?" to "are we learning, adapting, and staying aligned under pressure?" This theory emphasises that governance isn't something that sits above care; it's actually enacted within everyday interactions, decisions, and relationships. Something that those of us working in this space will recognise and understand.

Conclusion

THE SOLUTIONS TO OF THESE CHALLENGES ARE LOCAL AND GLOBAL

What came across clearly in our discussion is that governance for integrated care relies on shared purpose that is rooted in place and community, works with the community as creators of health, as well as providers who work in partnership with those communities. Governance needs high quality information to inform decision-making and ensure that resources are properly stewarded. Great governance is an essential component in creating the conditions for a learning system that is constantly responding to and initiating change. Less focus on structure and form to exert control and more on stewardship for community well-being is the way forward.