Joint Health and Wellbeing Strategies are important and will continue to be so, even under the new ICS system.  As I’ve said in these blogs a number of times, I think they generally do not seem to do what a good strategy should.  I’ve tried to explain what a good strategy should look like a few times and to give an example of what one might look like.  However, even if that ideal can’t be achieved, I think many strategies could still be improved, even within their existing limitations.

Generally, there is a problem with JHWS’s, that they are very similar to each other as if they are copying the general style rather than working out what is really needed.  However, some of the basics which could increase their chances of success, do appear in a number of strategies, so this is something where they could learn from each other.

Quite often, a JHWS is a vague statement of intent, picking a handful of issues and, in effect, saying ‘we will do something about them’.  But how can members of the public in those areas have assurance that something will be done and that it will deliver something of value?

My suggestion, which I don’t think is contentious, is that strategies should include three things: (1) arrangements for independent monitoring of (2) what is being done and (3) what is achieved. 

Independent monitoring is not something I remember seeing in any strategies, but I wouldn’t be surprised if some areas do this.  While Health and Wellbeing Boards do typically monitor progress in implementing their strategies, this could be seen as ‘marking their own homework’.  Independent monitoring should give greater confidence in the process and could act as a spur for the relevant bodies to make sure they are taking the necessary action.

Independent monitoring could come, for instance, from a broad group of members of the public and other stakeholders meeting once a year, in public, to review the evidence on action and progress and make recommendations.  It should be large enough to have people representative of all parts of the community.  It should use deliberative techniques, where expert evidence is provided to help them make judgements.  It would need to be well facilitated to ensure fair and equal participation and best use of time available (such as the use of sub-groups and perhaps online discussion).  This would not be simple and there would no doubt be all sorts of issues such as how the group should be selected, whether there should be continuity over time or different members each year, but it should be possible to resolve those.

The first thing, I would suggest, that these monitoring bodies should asses, is what has been done to implement the strategy.  This is to some extent straightforward.  It includes reporting on actions taken and how they fit into the bigger picture.  If there is an objective, say, of “helping people to access jobs”, you really need some idea of how this is to be achieved.

However, there is also something more specific that the monitoring should check on.  Most strategies identify some areas, typically 3-5, that they will focus on.  These are variously described as priorities, outcomes, objectives, areas of focus etc.  However, it is generally not clear in what way these issues will be “prioritised” or what will be different about them.  Will more resources (money, people’s time etc.) be spent on them (and if so, is it in absolute terms, relative to other areas, relative to what was spent in the past, or what)?  Will more attention be given to them?  The strategy should spell out in what way they are being prioritised and how that is measured.  If mental health is a priority, how is what happens on it going to be different from what happens on cancer?  If there is to be a focus on early years, how will what is done be different from what is done for looked after children? 

I suspect that usually there is no clear idea of what is meant by priority, focus etc. just a vague sense that we’re going to treat this as something important.  It would be helpful then, though difficult, to measure a number of different ways in which this is being treated as important.  That should include the amount that is spent on each priority. That won’t be easy because many different service areas will contribute towards any given priority.  However, to the extent that it is possible, it should give some idea as to how seriously the priorities are being progressed.  In answering to the independent monitoring body, the authorities should be able to show how each priority has, say, been top of agendas, how commissioning has been adjusted to deal with them and what strands of work they have led to.

The third element of my suggestion for what should be included in strategies is monitoring what is being achieved.  There are two aspects to this: firstly, knowing what it is and how it is to be measured and secondly, having some idea of the magnitude of change.  This is essentially having an idea of where you want to get to and having a way to judge whether you have got there.

Having clear measures of what you are trying to achieve can itself be an incentive to action; even without a specific target, if something has a performance indicator, people generally want to improve the number.  It is quite an art to find the right performance indicators and this is something where areas can learn from each other.  A number of problems are apparent in just flicking through existing strategies.  Many leave the identification of performance indicators to a later stage.  This is understandable since identifying the right indicators is very difficult.  However, if it can’t be done while the strategy is being prepared what will be different to enable it to be done later?

A second best to identifying the specific indicators is to describe in general terms what is to change, even if you don’t know yet how it is to be measured.  The risk though is that no way of acceptably measuring it can be found.  Also, with ambitious objectives such as ‘reduce levels of poverty’, you wonder realistically how much can be achieved and whether they will be held to account over it.

Something else that you frequently see is long lists of performance indicators but the ones which are already collected anyway.  Using existing indicators isn’t a problem – developing new ones is not straightforward – but the risk is that they are not a close enough fit to the changes you actually want to measure.  Another problem is indicators that do not cover the breadth of the ambition.  For instance, an objective to ensure all children and young people feel safe and supported in all areas of their life is admirable, but if the only measures are in relation to looked after children, having an up to date SEND plan and hospital admissions caused by injuries, then it seems unlikely that you will be able to tell whether you are achieving what you set out to.

The other aspect of identifying what you are trying to achieve is having an idea of the magnitude of change expected.  For health and wellbeing strategies this will not generally be having a specific target.  If you are looking at the big picture and long term, within a complex system, you are unlikely to be able to estimate exactly what you are likely to be able to achieve.  However, it can be helpful to have an idea whether you are hoping to shave a couple of percentage points off an indicator or whether you have an ambition to cut it in half.  This is important so that there is something by which to judge the success of the strategy and so there are shared expectations.  Having an idea of the magnitude of change can help judge whether particular actions are likely to be sufficient to achieve it.  It also means that the various partners are more likely to be on the same page about what needs doing.

Objectives or ‘priorities’ that do not do this, are ones such as, ‘reduce tobacco use’ or ‘reduce the need for children to be in care’.  Positively changing such an outcome for a single person would be all that was needed to achieve the objective.  But presumably there is an ambition to do more than that.  But what?

On the other hand, Camden’s objective to “Halve the proportion of children aged 10-11 who are obese, and to halt the trend of rising rates of overweight in this age group” tells you very clearly the sort of thing you are expecting the strategy to achieve.  The use of ‘halve’ rather than ‘reduce by 50%’ is important: this is not about having a red flag if the reduction is 47% rather than 50%, it’s about having some idea of the scale of the aspiration.

These suggestions are hardly radical.  Monitoring inputs and outputs are standard parts of any performance management.  Independent monitoring is perhaps not quite so standard but is still not beyond the pale.  It is surprising, then, how often these things are not done well in existing strategies, but there is hope that by learning from each other, there could be significant improvements.