Why haven’t Health and Wellbeing Boards produced strategic health and wellbeing strategies?
Having suggested what a strategy should include and assessed a number of Joint Health and Wellbeing Strategies (JHWS’s) and concluded they do not generally include what a strategy should, I now want to briefly consider why that might be.
This is largely speculation, because I haven’t been able to find any research that provides definitive answers. However, this draws on my experience of discussing the issues at local level with a number of people, including Health and Wellbeing Board members, and some people with a national perspective. The point of at least thinking through what the problems may be, is, in a later blog, to suggest how things might be done differently in future.
I will address this by first considering some possible individual factors (awareness, will, individual capacity) then collective capacity and finally external factors.
The first factor, awareness, is, I think, key. My experience talking to people involved with Health and Wellbeing Boards and JHWS’s is that I haven’t found any who understand what I’m saying when I describe the problem with JHWS’s. This naturally raises the question, am I right? I will consider that possibility at the end. But if I am right in my views on JHWS’s and if there is a widespread lack of awareness, that would be enough to explain why most JHWS’s are as they are. Certainly most strategies cover short periods, typically three or four years with more of a focus on operational issues. Kneale et al (2018) found only 12 out of 76 covering a longer period.
This may not totally provide an answer because there may be some awareness at some level – e.g. the feeling that the strategies should cover longer timescales and be more ambitious without necessarily knowing what they should look like – and other factors may still contribute to the problem. But even if awareness explained it all, on its own, it is worth also considering the other factors because if the problem of awareness was solved, they could then still be obstacles.
The second factor is individual willingness to do anything about it. It is easy to see why people might, perhaps unconsciously, resist doing anything about it. Trying to take a strategic approach is quite hard. It means thinking things through in some detail which is time consuming. It means working with partners and other people which can be tricky and frustrating. If, instead, someone can be deputed to go away and write an innocuous (but ineffective) document which ticks all the relevant boxes, why not just allow that.
There may be a lack of ambition in relation to strategies. If someone wants to move forward in their job and make an impression, there may be easier ways to do it, and ways which will reflect more on them individually, while a successful strategy should be a collective endeavour so is less likely to benefit any particular individual.
The next category is individual capacity. Are there individuals in the locality with the knowledge, skills and aptitude to think strategically and produce a strategy? I suspect there is some lack of knowledge, which ties in with the awareness point. Most people will have some idea what a strategy should look like, but, perhaps, it is limited.
On the other hand, I think there will usually be plenty of ability to do what is required, with the relevant motivation, guidance or training. Concepts such as social determinants of health, systems thinking and complexity are reasonably well known, at least to some degree. Having been in contact with many local government officers and members and health officials over the years, I have found many who have not just great practical ability but who can also think creatively and imaginatively.
The next category is collective capacity and here again I think there may be a problem. I have seen very experienced and capable people who could individually do a pretty good job, become, as a whole group, surprisingly inept: apparently operating at the lowest common denominator of the group. This may be the result of a combination of the other factors: the vast majority not having an awareness or knowledge of what is possible and it not being worth while for those who do have some idea, to question that and rock the boat when that would just lead to a great deal more work.
One thing I am unsure of is how far public engagement has been used effectively and whether giving members of the public free range to think creatively about the issues makes a difference.
The final category is external factors. Factors that operate against a truly strategic approach might include different imperatives and restrictions for health than local government, including to do with finance, targets, rules and timetables. National policies can also help or hinder local action. The private sector can also be significant.
For instance, commercial forces dramatically affect the sort of food and drink that is easily and cheaply available to people. The rise in processed food has been blamed for the increase of obesity alongside malnutrition in developing countries. The presence of fast food outlets near schools, the ease of gambling and the provision of alcohol all affect people’s behaviour.
The ’ideal’ strategy would involve a partnership between national and local. National government would be pursuing policies that, together with action at the local level, were fundamentally addressing the social determinants of health. The English NHS’s Five Year Forward View and Long Term Plan would have been joint health and wellbeing strategies writ large – developed jointly with local government representatives, the voluntary and ideally also other sectors. Instead, health introduced new, competing structures – strategic transformation partnerships and integrated care systems.
The other key way in which local areas have been at the mercy of the centre is through funding. Funding of local government has been centralised to a remarkable degree. Capping, and then the requirement to hold a referendum on any council tax increase over 2%, in practice eliminated council’s decision making. Funding from income tax, redistributed to promote fairness, allowing for different demands in different areas, has become seen increasingly as the Government beneficence rather than this being local government’s money which they own and control.
Health spending has been kept well below long term average increases and at an insufficient level to meet rising levels of demand. A top down approach, through punishments and rewards, has attempted to influence local spending, with the natural unforeseen consequences. Insular attempts to keep within the health department’s budgets have seen capital funds repeatedly raided to fund revenue, with the long term consequence that investment that could have generated larger savings and improvement further down the line, was not undertaken.
Also of significance, is the lack of external support that might help. Producing a good strategy is difficult, but by pooling resources (local areas banding together or through national bodies), a great deal of expertise and resource could be addressed at the problem which could do perhaps 60 or 80% of the work of producing a strategy. There would still be a need to address local issues, but much of the strategies of different areas would fit within a limited number of patterns. So a major impediment is possible lack of awareness at this level.
The final possible explanation for a lack of good, strategic thinking, is that perhaps, I am wrong.
Learmonth et al (2018) identify a number of positive elements of some of the early health and wellbeing strategies. This recognises health and wellbeing as part of complex adaptive systems and the opportunities for transformation. Although this is based on only 12 strategies from the north east of England, I recognise the characteristics in many of the other JHWS’s I have looked at. Among the positives they mention are:
- Linking the whole system into their strategy, such as noting the importance of social determinants of health
- The use of Marmot’s six strategic priorities (such as ‘give every child the best start in life’)
- Five out of twelve strategies linked wellbeing and place shaping
- Six out of the twelve strategies used the concept of transformation and ‘some’ included system change alongside topic based priorities
This appears to confirm that individuals are familiar with ideas such as prevention, social determinants of health and system change but it is consistent with my view that the various factors are not brought together to identify an ambitious and workable way forward over the long term.
Similarly, Hunter et all found a lack of joining up in relation to the Joint Health and Wellbeing Strategy and other policy initiatives, finding that
“… there was (at both strategic and operational levels) little ownership of the JWHS, with a lack of accountability for elements of the strategy. The strategies were not regarded as an integral part of the health and social care landscape.”
But despite that, I could still be wrong. Maybe these strategies are not there waiting to be written. Perhaps, instead, what has been produced is as good as it gets. To address that possibility, I will try, in the next blog, to produce some broad outlines of what a good health and wellbeing strategy might look like.
Hunter, David; Perkins, Neil; Visram, Shelina; Adams, L.; Finn, R.; Forrest, A.; Gosling, J., Evaluating the leadership role of health and wellbeing boards as drivers of health improvement and integrated care across England, 2018 April.
Kneale, Dylan; Rojas-García, Antonio; Thomas, James; Exploring the importance of evidence in local health and wellbeing strategies, Journal of Public Health, Vol. 40, Supplement 1, pp. i13–i23, 2018.
Learmonth, Alyson; Henderson, Emily J,; Hunter, David J., Securing systems leadership by local government through health and wellbeing strategies, Journal of Public Health, Vol. 40, No. 3, pp. 467-475, 2018.