Just how strategic are Health and Wellbeing Strategies?
I have long thought that our local Joint Health and Wellbeing Strategy (JHWS), and most of the others I have seen, are not very strategic. They don’t do a good job of identifying a way in which ‘the whole system’ locally (including patients and the public), over the long term, could make a substantial difference to health and wellbeing. When I have tried to explain this to people they generally don’t seem to understand or accept what I’m saying (although one strategic director conceded the point but maintained that it was too difficult, so better to just get on with operational improvements). So, over a series of blogs, I am trying to set out the argument in more detail.
In the last blog, I described the essential features of a strategy. Now, I want to assess to what extent ‘the typical’ JHWS possesses those features. This is based on looking at about a quarter of the 151 strategies. Although they vary, and some are better than others, most are quite similar in their key elements.
So, what does a typical JHWS look like?
There is an overall objective, but often expressed in very general terms, such as ‘to improve the health and wellbeing of local people and reduce health inequalities’.
There is some background information such as what a JHWS is, the process followed to produce this one, the state of health and wellbeing in the area and what has been achieved so far.
A number of priorities are identified, sometimes sitting within wider themes. For each, there is sometimes information supporting their inclusion as a priority, the identification of projects or pieces of work to address the issues and an indication of what is to be achieved over a period of 3-5 years, which could include a number of performance indicators.
There may be something on delivery and governance such as delegation of each priority to some group or committee and a means of holding them to account for achievement of results.
Much of what they say is relevant and important. But much, also, is missing. And overall, I wouldn’t describe that as a strategy. Or not a good one. Or not as good a one as it could be. So, what’s wrong and what’s missing?
The key features of a strategy I identified in the last blog were:
An objective. It should be clear where you are trying to get to. It should be about meeting fundamental aims, (rather than, say, instrumental ones, such as increasing the number of people receiving a particular service).
It should be long term and large scale. This is relative, but generally for any given entity, the larger the scale and time period, the more strategic.
Analysis including considering possible changes in the broader environment (economic, social, technological etc.) should be undertaken.
There should be a consideration of what could be done differently. There should be an indication that alternatives have been generated and evaluated, and ideally it should say what they are and why the selected one was chosen.
An approach to meeting aims. This is the essence of the strategy. There should be an approach which shows how the fundamental aims will be met. Given the uncertainty of the complex systems that health and wellbeing are part of, a detailed plan or blueprint is unlikely to be practical. So while there may be a general, high level plan, with a sense of the changes being sought in different areas and how the various factors interrelate, it may be that the way forward is defined in other ways. It may be about positioning, (such as being the sort of system where people are supported to manage their own health more). Or it could be the process to be used for following through on the strategy, (such as: piloting approaches, reviewing and scaling up; or using community engagement to drive the process). But one way or another, it should be clear how this sort of approach will help meet the aims and why it is better than other possible approaches.
To have confidence in the strategy, you would want to be assured that there had been comprehensive engagement, a thorough analysis, consideration of alternative approaches (ideally considering innovative ones and ones which push boundaries), a reasoned and evidence based selection of the approach and an indication that this can be achieved and how.
So how does the ‘archetypal’ strategy match up to this definition?
Objective. Most strategies have an objective but often it is too vague to be of much value. Improving health and wellbeing and reducing health inequalities may be the purpose of the partnership, but it gives precious little idea of where you’re trying to get to. The objective isn’t just something that you start with. It needs to be revisited after the analysis, when it may be clearer what can practically be achieved. Some strategies do have more specific targets, but these are generally about parts of the strategy, not the overall goal, and it is not usually clear how the target was arrived at. Because the strategies tend not to be ‘thinking big’ (see below) it is generally not clear what significant change might result from them.
Long term and large scale. Many ‘strategies’ are only looking three years ahead. This is not long enough to make a substantial difference to the issues that need to be addressed (such as radically altering behaviour in relation to diet and exercise, making fundamental shifts in the use of technology or service reconfiguration to focus on prevention and care within the community). Even five years, which some strategies work on, is barely enough. Even if the heart of the strategy is delivery over the next 3-5 years, it would be worth situating this within change to be made over a longer period. Only by looking 10 or 20 years ahead or even longer can you properly consider changes over the life-course and generational changes.
Another way in which scale is often insufficient is in excluding key parts of ‘the system’ of health and wellbeing. More of our health and wellbeing is determined by services outside of the NHS (particularly local government, such as transport, environment, housing and leisure) and by individuals, their families and friends than it is by the health service. While these are sometimes mentioned, the extremely difficult challenge of how to bring all this together is not usually addressed.
Because of the shorter timescale, many of the proposals are in effect ‘business as usual’. Now, it may be that continuing with existing or similar policies and projects is the best that can be done, in which case it would mean that the best strategy was already being followed. However, to demonstrate that would require consideration of alternatives, some analysis and justification, which have not been present in any of the JHWS’s I have seen so far. More likely is that a bigger ambition is not being recognised and grasped. The listing of policies and projects also generally fails to identify the relationships between them and how they could support each other.
Analysis, including considering changes in the environment. Although there is sometimes a brief description of likely changes ahead, such as the ageing population, any kind of serious analysis is almost invariably missing. This could be because the published strategies are generally public facing. While it is good to have an easily accessible version (and some are commendably simple), focussing on the conclusions, there is no obvious reason why there should not also be a more substantial document which includes a full analysis, consideration of options etc. It could be that this detailed work has been done in the background, but I have not seen any evidence of that in the strategies reviewed so far.
Is it realistic to produce great long documents, and would anyone read them anyway? Producing the JHWS is one of the key roles of the Health and Wellbeing Board (HWB) and I have seen lots of HWB agendas running to a hundred or two hundred pages, so I would say, yes, it is realistic. Would it be read? If it supported an ambitious programme of change, then yes, it would be a reference point for how the conclusions were reached, and each time the approach was reviewed, a starting point to take it further.
A consideration of what could be done differently. The analysis should produce options for different approaches to meeting the objective. I have not seen this in any JHWS examined so far. At the very least, there ought to be a justification as to why the priorities or areas of focus have been chosen. Just indicating that it is a problem, such as by giving the numbers of people affected and how, is not enough. That does not, on its own, explain why those have been selected rather than others.
An approach to meeting aims. This is the essence of the strategy but is all too often missing. The strategies that do this best, grasp the big underlying changes that need to happen, such doing more on prevention, increasing supported self-help and greater exploitation of technology. These are often in line with existing strategies such as the NHS Long Term Plan, such as a move away from acute and towards community care. Those could genuinely by described as strategies. But even here, there are usually two weaknesses. Firstly, it is not explained how these conclusions were reached and how these proposals compare with alternatives. Secondly, it is not always clear how they are to be achieved. This is particularly so with prevention, which is often mentioned but usually to be implemented through Public Health rather than across the ‘whole system’ and with no increase in resources.
However, most JHWS’s do not even have this. A more common approach is to identify a number of priorities or areas of focus, sometimes within broader themes. Identifying priorities in a strategy sounds like common sense. After all, you can’t do everything, so why not focus on the key four or five things that could really make a difference? There are two main problems with setting priorities in this context. Firstly, it is not clear what is meant; in what way these will be priority areas. And secondly, it is not clear how focussing on those areas constitutes a strategic approach.
The first problem is not being clear what is meant when identifying priorities. To prioritise means putting into order of importance, but also selecting a small number of things to be done, to the exclusion of others. The reason for identifying priorities is that one or more sorts of resource are limited and there is a minimum that needs to be allocated to make it worthwhile pursuing any single one. For example, the top team has a finite amount of time and can only give serious, consistent attention to a limited number of issues, so they prioritise and decide which they will focus on. That doesn’t mean that other things don’t get done in the organisation or partnership – actual activity in total isn’t being prioritised – just the attention of the top team. Of course, there may also be some prioritising of resources – the priority areas may get more money. However, assuming other areas still get some funding, this is not prioritising in the same sense of selecting a few things to the exclusion of others. On the other hand, if there was some limited extra funding and this was split up between the four or five key areas, you might say that this extra funding had been prioritised.
So, when a Joint Health and Wellbeing Strategy says it is prioritising, say, prevention, loneliness, mental health and young people, what does this mean? It doesn’t mean that action and spending on other areas will stop. Does it mean the priority areas will receive more resources and if so, relative to what? Relative to what they would otherwise have received, relative to other areas (how measured), or more of the extra resources available than other areas (or perhaps less of the cuts). If it is a prioritisation of attention, does this mean the time and attention of the Health and Wellbeing Board and any sub-committees or the individual partner bodies or of someone else? Does it mean services not directly involved in delivering those priorities (such as services other than mental health, if that is a priority) should give more attention to the priorities (and if so, has anyone actually told them that?)?
You could argue that it doesn’t matter: it will be some combination of attention and resources. However, the risk is – and it is a risk that I have seen materialise – that prioritisation does not happen in a significant or meaningful sense, in any sense that actually makes a difference.
This leads to the second problem with the use of priorities. If what is meant by ‘priority’ is that this is where the Health and Wellbeing Board (HWB) is focussing its attention, that suggests that the HWB is to deliver the strategy. But the HWB is a partnership, not an executive body with its own resources (one complaint I have heard on a number of occasions is that the Board can’t do anything decent because it doesn’t have a budget). Its role (alongside producing the Joint Strategic Needs Assessment and promoting integration), according to the 2012 Health and Social Care Act, is to produce a strategy which influences commissioning by the CCG and council.
While it is not generally the HWB’s role to deliver the strategy, there are two ways in which the HWB could legitimately be involved in delivery. Firstly, if resources and structures have been pooled and combined (such as through the Better Care Fund), the HWB (or a sub-committee) could be the executive body having oversight and control of that area. Secondly, it could have a continuing role not directly in delivery but in co-ordination. Rather than producing a strategy and then hibernating for five or ten years while its partner bodies implement it through their commissioning, the strategy could be more of a living process, with amendments and variations made by the HWB on an ongoing basis. The Board would provide co-ordination and be ready to respond to the realities on the ground and make changes to the original strategy, which was being implemented by the partnership.
However, that does not seem to be what is intended in most cases when the HWB sees itself as responsible for delivery. For instance, there are examples where the priority is delegated to a sub-group who are expected to just get on with it, which turns out to be through a series of small-scale, ad hoc projects detached from the big, strategic decisions which are being taken elsewhere.
If the selection of priorities were really to be strategic, these would have to be the things which would really make a difference (more so than anything else). It also implies that something in those priority areas has not been happening as it should before (e.g. insufficient resources or a sub-optimal approach) and that this is going to be different in future. Neither of these is generally spelled out in the strategy.
There is also generally no indication of how the different priorities interrelate and how greater gains could be achieved by making use of those interrelationships (for instance physical and mental health affecting each other, work with children then influencing their families etc.).
Which brings us to delivery and governance. If particular priorities are allocated to a specific group, which will be ‘held to account’ for delivery, it sets alarm bells ringing. It is not that there should be no breaking down of tasks to different groups, but co-ordination is often not mentioned, and ‘holding to account for delivery’ implies that change can be achieve regardless of the wider system of which they are a part.
So, in summary, why is this archetype I have been critiquing not a strategy, or a decent one, or not the best it could be?
- There is an aim, but it’s too general (improve health, reduce health inequalities).
- It’s too short term (three years, or five at most) and too small a scale, to be able to make much difference.
- It doesn’t include ‘the whole system’, in particular the participation of patients, the public and service users.
- It doesn’t look at possible changes in the environment or provide a comprehensive, coherent analysis.
- It doesn’t look at alternative approaches for how the strategy is to work or give reasons for what approach is chosen.
- It doesn’t understand or use priorities appropriately, so it is unclear how they will be progressed or how that will contribute to achieving fundamental aims
- The Health and Wellbeing Board is seen as a delivery vehicle rather than a forum for producing the strategy and then co-ordinating its implementation and revising and adapting it over time.
- It doesn’t show how the proposed approaches are likely to achieve the aims.