Wellbeing boards are crucial to post-Francis accountability

At the heart of the Francis report there is a clear imperative to improve health and care system accountability. Despite progress in promoting a culture of transparency in healthcare services, the risk of systemic failures persists.

The question of who should be held accountable remains unanswered. The public uproar on local decisions, such as hospital closures, reflects the challenging landscape of local accountability.

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Yet there is a notable lack of mechanisms for accountability in multi-organisation systems.

Protecting confidence

The search for accountability options to avert future failures should focus on mechanisms that protect and promote public, professional and political confidence.

These would be characterised by strong professional credibility, evident democratic legitimacy and clear public acceptability.

They should also be flexible enough to ensure a responsive balance of local ownership and central oversight.

Health and wellbeing boards have the potential to provide a robust accountability platform for integrated health and care systems, and can also seize the opportunity provided by the better care fund to promote good governance.

Joined up thinking

Local government and the NHS will depend on each other for successful place shaping, which includes legitimising and making accountable integrated health and care systems. Health and wellbeing boards can facilitate this.

The health and wellbeing boards were established by the Health Act 2012 to promote integration in the commissioning and provision of local NHS, social care and public health services.

‘The better care fund is likely to lead to complex systems in which the need for robust accountability will be urgent’

The drive to integrate health and care services is exemplified by the government’s £3.8bn better care fund.

This “game changing” policy aims to address pressures on health and care systems, while building foundations for integration.

The intention is that local better care fund plans are jointly developed by clinical commissioning groups and local authority partners, and approved by the health and wellbeing board.

The policy ideals of the better care fund are appealing, but where commissioning is fragmented, potential may be limited. It is likely to lead to complex systems in which the need for robust accountability will be urgent and challenging, and the consequences of failure catastrophic.

Limited efficacy

It is difficult to argue with the rationale for health and wellbeing boards, but their effectiveness as platforms for strategic change in local health and care commissioning remains to be seen. They can influence commissioning, but board members must revert to their respective organisations to formalise decisions.

The hope is that the  board’s constituent organisations lead the system beyond organisational boundaries towards common priorities. However, this ignores the varying lines of accountability between partners and gives rise to the risk that the boards default into rubber-stamping, rather than shaping, decisions.

Furthermore, the models (professional, political and organisational) and components (loci, domains and enabling procedures) of accountability are complex.

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Despite this, little effort has gone into a robust analysis of accountability in the landscape in which health and wellbeing boards operate. Indeed, the models of accountability, and the interactions of their components in integrated health and care systems, remain largely unclear.

These are hardly academic questions. Ensuring that the clinical commissioning process is open to public and political scrutiny, as well as being organisationally accountable, is a real challenge.

Without a thorough and open analysis of accountability matrices in local systems, health and wellbeing boards could fail in their duty of driving accountable high quality integrated health and care.

Local governance

As the policy of integration embeds locally, accountability will come into greater focus. It is as important to have good governance between organisations in a system as it is within component organisations.

‘As the policy of integration embeds locally, accountability will come into greater focus’

This requires mechanisms to ensure resources and decisions that recognise success and failure as no longer “belonging” to a particular entity but to the whole system. So the Commons health committee’s recommendation that HWBs assume leadership of local strategic commissioning is timely.

To achieve this boards will need to influence constituents to work together towards improving patient outcomes by establishing a common vision of health and care priorities. Single outcomes frameworks, supportive political environments, citizen participation and integrated information systems must all work in agreement.

Pivotal role

Health and wellbeing boards are well positioned to take on this role. Their members represent three key groups:

• The right blend of professional groups: clinicians, public health, social care, children services and other service managers. They can help the board fulfil its role by working to a single and clear outcomes framework. A single framework is likely to lead to growing budget pools which, in turn, will increase clarity of purpose and enhance resources for tackling problems.
• Public and patient community groups (HealthWatch). They ensure that citizen involvement is integral to its decision making. So the boards have an opportunity to define and communicate locally what choice for health and public services means. This can create the culture of genuine citizen control that is an aspiration for public services.
• Democratically elected leaders who hold health and wellbeing or social care responsibilities for local authorities. Their democratic mandate and unique insight into their communities means they can bring legitimacy to decision making.

Each of these groups has its individual set of values that inform their choices and actions as part of the board. The combination of professional credibility, public acceptability and democratic legitimacy gives the board strong system-wide credentials.

‘The combination of professional credibility, public acceptability and democratic legitimacy gives the board strong system-wide credentials’

However, this will remain only a potential without clarity about how to realise it. A rigorous analysis of the models of accountability in health and wellbeing boards and the local systems of health and care that they lead is needed.

The government requirement that all local better care fund plans should be approved by their respective health and wellbeing boards presents opportunities for them to assert leadership and establish a platform for accountability. This will test their ability to offer credible, shared leadership now, while presenting them with a chance to demonstrate readiness to play a bigger role in the planning and commissioning of all local health and care services in the future.

Promised land

Health and wellbeing boards hold a lot of promise. The board’s single overview for a community, through the engagement of local professionals, politicians and lay people will provide greater understanding of the health and care issues, and ultimately help to improve public trust and confidence in the system.

The introduction of the better care fund will be timely. Its conditions, mechanisms and aspirations provide a lever through which health and wellbeing boards can drive up accountability. There is, however, a need for better understanding of how political, professional and organisational accountabilities interact within an integrated local system.

Aliko Ahmed is director of public health for Staffordshire County Council and Kelechi Nnoaham is director of public health for Plymouth City Council