How to Make Shared Governance Work: Navigating the NHS and Independent Sector Divide
A growing share of NHS-funded care now happens in independent hospitals. As of 2022, the independent sector delivered around 9% of all NHS-funded elective procedures, and for hip and knee replacements and cataract surgery specifically, that figure rises to roughly one in three. NHS spending on independent sector care reached £11.8 billion in 2020/21, up £2 billion on the year before.
This isn't a niche arrangement at the margins of the system. It's a substantial and growing part of how NHS-funded care actually gets delivered.
Nearly all of it runs on a shared medical workforce. Most consultants working in independent hospitals hold a substantive NHS post, and their NHS employer carries legal responsibility for oversight of their whole scope of practice, including the work they do on the independent side. Which raises an obvious question: when a consultant's practice spans both sectors, how well does governance actually follow them across that boundary?
Until this year, the honest answer was mostly anecdotal. A national survey published in 2026 changes that. Researchers from the University of Manchester and University of York surveyed 769 senior leaders with governance responsibility across NHS trusts and independent hospitals in England; 320 responded (a 42% response rate), and asked, in detail, how shared clinical governance actually functions between the sectors. The findings are worth taking seriously, because they confirm something many independent providers have probably suspected but rarely seen measured: shared governance across this boundary runs largely on goodwill, not process.
The headline finding: informal is the norm, not the exception
Only around one in five respondents said they had a formal agreement or policy governing shared clinical governance arrangements with their counterpart hospitals in the other sector. The rest relied on contact of varying frequency, described by respondents as ad hoc, sporadic, and reactive: meetings that happened when something went wrong, rather than as a standing part of how the relationship worked.
Where relationships were strong, they tended to be strong with one or two specific partner hospitals, and considerably weaker, sometimes non-existent, with others, even where consultants were shared across all of them. The researchers found this pattern repeatedly: a good relationship with the hospital down the road, and almost nothing with three others where the same doctor also holds practising privileges.
The mechanism holding this together, more than anything else, was personal relationships. Responsible-officer-to-responsible-officer conversations were the main channel respondents described. When those individual connections existed, the system worked reasonably well. When they didn't—because of staff turnover, a large multi-site independent group with too many NHS trusts to build relationships with individually, or simply no prior contact—governance information didn't reliably flow at all.
The perception gap independent providers should sit with
Here's the finding that's genuinely worth pausing on if you're on the independent sector side: when asked to rate the quality of their shared governance arrangements, independent hospital respondents rated them significantly more positively than their NHS counterparts did—a statistically significant gap, not a marginal one. Nearly two-thirds of independent sector leaders rated their processes for verifying consultants' scope of practice as robust; fewer than a fifth of NHS leaders said the same about theirs. Three-quarters of independent sector leaders were confident they knew the NHS scope of practice of their dual-practice consultants; under a third of NHS leaders had equivalent confidence about the independent side.
Interestingly, the survey suggests the complexity runs the other way round from what you might expect: independent hospital respondents most commonly reported that their consultants come from three or more different NHS trusts, while NHS respondents mostly said their consultants who also work independently were active at just one or two independent hospitals—and over a third of NHS respondents didn't know which independent hospitals their consultants worked at, at all. If anything, independent providers are often the ones managing the wider spread of relationships, which makes the confidence gap more striking, not less.
This is worth sitting with because it means an independent provider can genuinely believe the relationship with its NHS partner is working well, while the NHS side experiences the same relationship as thin, uncertain, and hard to rely on. If your own confidence in shared governance rests entirely on your side of the process feeling solid, that confidence may not be shared by the trust you'd need it from in a crisis, and you may not find that out until you actually need it.
Where the practical risk actually sits: scope of practice and probity
The survey asked in detail how organisations verify a consultant's scope of practice at the other hospital, and how concerns get shared. The pattern that emerged across both sectors was a heavy, largely unavoidable reliance on the consultant's own honesty.
NHS respondents described relying on a "letter of good standing" provided at appraisal, self-reported by the consultant, rarely independently verified. Independent hospital respondents described a similar dependency running the other way—scope of practice information supplied by the consultant when applying for practising privileges, sometimes supported by a letter from their NHS trust, but frequently not checked in any real depth afterward. One independent sector hospital director's own assessment, reported in the study, was blunt: they were relying on trusting that the consultant was telling the truth, and probably weren't rechecking scope of practice as often as they should.
This matters more than it might first appear, because it's precisely the gap the Paterson Inquiry identified after Ian Paterson was able to continue harming patients across both NHS and independent settings, in part because information about his practice wasn't being systematically shared between the organisations where he worked. The Inquiry's first recommendation called for a single, shared repository of consultants' whole practice, accessible to both sectors. A pilot of exactly this—the Acute Data Alignment Programme (ADAPt), run jointly by the Private Healthcare Information Network and NHS Digital—ran between 2020 and 2023. It has not yet been implemented nationally. Five years after Paterson, the infrastructure recommendation still doesn't exist in practice, and the survey's findings show why that gap continues to matter: without it, verification still depends heavily on the consultant's own account.
This sits close to what medical revalidation is meant to capture in the first place—a doctor's whole scope of practice, wherever they work. The survey shows plainly that, in practice, the mechanism to evidence that fully across sectors still isn't there for most organisations.
Concern-sharing looks better on paper than it works in practice
Most organisations do have a policy for handling concerns about a consultant's practice, 79% of NHS respondents and 93% of independent sector respondents confirmed this. But having a policy and having concerns actually reach the other sector in practice are different things. Only 64% of NHS policies specifically included a process for sharing concerns with the other sector hospital, against 93% of independent sector policies.
When asked directly whether consultants fulfil their professional obligation to inform other organisations about significant concerns, restrictions, or exclusions, the most common answer from NHS respondents wasn't yes or no, it was "I don't know," at nearly half of all responses. Only around one in ten NHS respondents and roughly one in five independent sector respondents felt this always happened. Respondents from both sides described a system that, in practice, isn't a genuine two-way exchange: independent providers frequently reported passing information to the NHS without it being reciprocated, and vice versa, often attributed to unclear ownership within large NHS organisations (where responsibility bounces between the Medical Director, the Responsible Officer, and divisional leads) rather than any deliberate withholding.
What this means practically for independent providers
None of this is really an indictment of individual organisations trying their best within an unregulated, non-mandatory process. This is a structural gap, not a behavioural one, and the researchers are explicit that it needs systemic fixing, better data infrastructure, and full implementation of the Paterson recommendations, rather than individual organisations solving it alone. But waiting for that infrastructure to arrive isn't a governance strategy. Here are five concrete steps worth taking now:
Don't treat a "letter of good standing" as verification. It's a useful data point, but the survey shows plainly that both sectors know these rely on the consultant's own account rather than independent checking. Where you can, build in an actual verification step—a direct conversation with the Responsible Officer or equivalent at the other organisation, not just a form.
Formalise the relationship, even informally. You don't need a heavyweight contract to move from ad hoc to structured. A simple written understanding—who the named contacts are on each side, how often you'll touch base, what triggers an out-of-cycle conversation—closes most of the gap the survey identifies between "some contact" and "an actual formal agreement," which only one in five organisations currently have.
Don't assume reciprocity. The survey found information sharing was frequently one-directional, more often independent sector giving without receiving back. If you're only getting what's volunteered, build in a habit of actively asking, rather than waiting for information to arrive.
Build resilience beyond one relationship. Where governance depends on one individual's personal connection with one RO, it collapses the moment either person moves on. Document who holds the relationship and make sure at least one other person in your organisation has visibility of it.
Watch the Paterson recommendation timeline. The infrastructure gap this survey identifies is a known, named policy priority. When ADAPt or an equivalent shared data system does move toward implementation, providers who've already built strong internal scope-of-practice and concern-sharing habits will adapt far more easily than those relying entirely on goodwill today.
This is exactly the kind of gap that sits between disciplines—part clinical oversight, part information governance, part plain organisational habit—which is precisely why it tends to fall through the cracks of governance built around a single specialism. It's also exactly the kind of standing, cross-disciplinary assurance work we build into ongoing governance support for independent providers, rather than treating it as a one-off policy exercise.
Source: Stringer G, Ferguson J, Walshe K, et al. Shared clinical governance arrangements between NHS and independent acute hospitals in England: findings from a national survey of senior leaders. Journal of Health Services Research & Policy, 2026. Funded by the NIHR Health and Social Care Delivery Research Programme.
