40 Suffolk and North East Essex ICS | ‘Our Journey Together’ 5.5 Actively redistribute power Recognising power imbalances Power imbalances are extremely important to consider in the context of health and care system working. A power imbalance occurs when one party in a conflict has more influence, control, or authority than the other (for example as a funder, commissioner or more powerful organisation with statutory responsibilities). This imbalance can manifest in different forms, such as: • Hierarchical power (e.g., commissioner vs. contractor) • Resource control (e.g., access to knowledge and information, control over finances) • Cultural or social power (e.g., differences in gender, race, or in health and care in sector) • Psychological power (e.g., one party uses manipulation, there is fear of exposing ignorance, or there is unconscious intimidation to dominate or a lack of parity of esteem) Power imbalances can make it difficult for the less powerful party to express their views or negotiate effectively, often leading to unresolved tensions or long-term conflict. Some stakeholders also highlighted that, in the context of Integrated Care Systems, where there can be a lack of understanding about what the system is, its aims and its complexities, this in itself could inhibit partners from engaging with the ICS. Stakeholders talked about how ‘progress happens at the speed of trust’ and how building trust within the system is fundamental. However, trust will not be built by avoiding conflict and the ability to surface conflict is one of the most important drivers of trust in partnerships — especially in complex, multistakeholder systems like health and care. Trust is built when people can disagree and still feel valued, respected, and aligned. If conflict remains hidden this can lead to “false harmony” where people nod but silently disengage, slow or poor decisionmaking, buildup of frustration, erosion of psychological safety and a loss of credibility for leaders who avoid difficult issues. Some smaller stakeholders told us that although they appreciated that local commissioners were enthusiastic about working with diverse partners, they often had a lack of experience in this area and failed to either properly understand or address the issues of an imbalance of power. They felt that NHS and local authority commissioners sometimes misunderstood that commissioning relationships are not necessarily partnership relationships and described actions and behaviours that clearly did not reflect best practice. Key to the development of the Suffolk and North East Essex ICS were the creation of various system forums and assemblies which enabled the necessary separation of powers and ways of working to enable conflict to be surfaced and a balance of powers established with partners. This involved a broad range of stakeholders including the VCFSE sector, social care providers, people and community representatives, elected and non-executive leaders, stakeholders outside the health and care sector etc. Picture – NHS ICB Chief Executive Ed Garratt in discussion with local social care providers in Suffolk, October 2023
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