Discharging democratic accountability: The role of strategy and performance information in local authority Health and Wellbeing Boards

The Health and Social Care Act (2012) required the creation of Health and Wellbeing Boards (HWBs) to provide strategic leadership for health outcomes for localities across England. It was suggested that HWBs would enhance democratic accountability and provide a forum for key leaders to come together from across the health and social care systems. This research explores the extent to which HWBs have, or have not, enhanced democratic accountability through the use of strategic planning and performance information. The study is informed by a total of 39 interviews with experts and members of two HWBs and has resulted in the following key conclusions: wUnderstanding of what is meant by democratic accountability was variable across the interviewees. Many interviewees felt that their key obligation was directly to their local public rather than being held accountable through the political process. The low level of public engagement with HWBs also suggests that democratic accountability is indirect and limited. w Many members of the HWBs also recognised that they felt they had multiple accountabilities. There appeared to be a tension between an interviewee’s perceived accountability for local health outcomes as a member of the HWB and their accountability for their own organisation’s operations in long-established accountability relationships. For instance interviewees representing organisations operating within the health service have long been accountable to NHS England and the Department of Health. wHWBs have been required to develop a Joint Health and Wellbeing Strategy, but doing so effectively has proved challenging. Our evidence suggests that important lessons have been learnt about the potential scope of HWBs as reflected in their strategy. Our interviewees point to how there has been a need to ‘refresh’ strategies and to reduce the number and scope of priorities. In particular emphasis has shifted to priorities where there is the potential for joint working from the different members of the HWBs. w We find that there is some level of agreement that, whilst the use of performance information in our two HWBs has been limited, it may become more important into the future. It is suggested that performance information accompanied by associated narratives could be used as a way to further improve the work plans and structure of HWB meetings. wHWBs are strengthened by the developing relationships between the key leaders from across the health and social care systems. Their potential to improve health outcomes, however, is inhibited by a lack of financial and human resources and a lack of integration and system leadership. Policy initiatives such as sustainability and transformation partnerships (STPs) also contribute to uncertainty that can hinder the progress of HWBs.