Editorial

Journal of Health Services Research &

Policy
Partnership and accountability in the era 0(0) 1–3
! The Author(s) 2019
of integrated care: a tale from England Article reuse guidelines:
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DOI: 10.1177/1355819619882959
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In England, the 2012 Health and Social Care Act was care system leaders, ‘bolt-on’ forums for collaboration
heralded to be among the most significant changes in such as Health and Wellbeing Boards might seem like
policy for the National Health Service (NHS) since its an answer to yesterday’s question.
inception in 1948. And indeed, it introduced major Perkins et al.’s study of five Health and Wellbeing
structural upheaval, and was followed by an increase Boards in England provides insight into their evolu-
in contracting for NHS services with private-sector tion,6 adding to a relatively slim knowledge base on
organizations.1 Yet a key theme of the policy, namely their role and function. Their findings are gloomily
the intensification of competition in service provision, familiar for those acquainted with the literature on
with a pluralization of providers and increasing choice partnership in health and social care: in the main,
for patients, has not fully materialized. Even as imple- Health and Wellbeing Boards appear to have been hin-
mentation of the policy began, the focus of NHS gov- dered by conflicting priorities, weak accountability
ernance was already shifting from competition towards arrangements and mistrust across organizations. As
collaboration. The 2014 Five Year Forward View out- health and social care became more complicated and
lined visions for a more integrated health and care fragmented in the wake of the Health and Social Care
system in England.2 Subsequent guidance introduced Act, joint working became all the more difficult.
new organizational forms, such as the so-called Despite being ‘the one place where the system can
Sustainability and Transformation Plans and integrat- come together’,6 Health and Wellbeing Boards
ed care systems3,4 with their focus on strategic planning seemed in the main to be little more than talking
within local health care economies, making the pur- shops, unable to coordinate the action that might
chaser–provider split, introduced in the English NHS fulfil strategic promise.
in 1991, seem increasingly redundant. The appointment In this brave new world of integrated care, however,
in 2019 of England’s first joint chief executive of a pro- one might ask to what extent to Perkins et al. downbeat
vider of NHS services and its principal ‘customer’ (clin- findings matter. If the authors of the NHS Long Term
ical commissioning group)5 perhaps marks the death Plan struggle to position them in this new landscape,
knell of the purchaser–provider split; it is now replaced can they not be quietly sidelined, as the real business of
by a more integrated, strategic and system-based system integration becomes something that senior exec-
approach to local health care planning and provision. utives in commissioning and provider organizations are
Reflecting this shift in the landscape, other aspects finally forced to attend to?
of the 2012 legislation, seen as welcome and innovative There are at least four reasons why Perkins et al.’s
features at the time, have received little attention. findings should be taken seriously if the NHS means
Clinical Senates (established across 12 regions in business when it comes to system-level integration. The
England) and Health and Wellbeing Boards (estab- first is the simple empirical message about how hard
lished in each local authority area) were introduced partnership is to do, a point whose familiarity only
as forums for multi-professional, multi-sector co- underlines its importance. In a regulatory and legal
ordination in planning care provision, and a means of context that remains formally governed by expecta-
mitigating the potential downsides of market-oriented tions of competition and contracting, and where per-
reforms, but talk of these forums in policy and academ- formance is still managed at the organizational rather
ic settings has gone rather quiet since. The 2019 NHS than the system level, collaboration is a risky endeav-
Long Term Plan, for example, makes just one fleeting our, as system leaders themselves have found.7
reference to both, noting the need for their alignment Second, the democratic function of Health and
with integrated care systems with a view to ensuring Wellbeing Boards is conspicuous by its absence in
clear leadership and accountability frameworks.4 many emergent integrated care systems. Although the
With integration and coordination front and centre in composition of Boards varies,8 all must include among
NHS England’s expectations of local health and social their members elected councillors, as well as senior
2 Journal of Health Services Research & Policy 0(0)

officials from both the local NHS and local govern- to make or break the sustainability of the NHS in the
ment. While their accountability arrangements may future.
be nebulous, Health and Wellbeing Boards do go Five years ago, a joint paper by the Local
some way towards addressing the democratic deficit Government Association and NHS Clinical
in local health care provision. The development of inte- Commissioners argued for a central place for Health
grated care systems, meanwhile, has been dogged by a and Wellbeing Boards in developing ‘a place-based,
sense that they have been subject to minimal public preventative approach to commissioning health and
scrutiny, putting them at risk of judicial review.9 care services, improving health and tackling health
Moreover, some campaigners warn that integrated inequalities’.14 Perkins et al.’s findings suggest that
care systems themselves might be ripe for contracting for several reasons, Health and Wellbeing Boards are
out to private providers wholesale,10 with the potential finding it difficult to take up this strategic mantle.6
to undermine democratic accountability still further. Developments in the integration agenda since then
Third, and relatedly, Health and Wellbeing Boards have made the need for such leadership more pressing.
incorporate the views of a range of wider stakeholders, If challenges around responsibility, accountability and
in line with their strategic and cross-sector brief. influence can be addressed, Health and Wellbeing
Membership includes local Healthwatch organizations Boards might yet become system leaders, rather than
(the independent ‘consumer champion’ for health and vestigial appendixes.
social care locally) and, in some cases, a range of other
bodies from the voluntary sector.11 Evidence suggests Declaration of conflicting interests
that patient, public and other stakeholder involvement
The author(s) declared no potential conflicts of interest with
in the development of Sustainability and
respect to the research, authorship, and/or publication of this
Transformation Plans has been rather restricted.9
article.
Again, a seat at the table seems preferable to exclusion
from conversations, even if the effectiveness of Health
Funding
and Wellbeing Boards is limited: soft influence is better
than none. The author is supported by the Health Foundation’s grant to
The final point relates to the purpose of integration. the University of Cambridge for The Healthcare Improvement
Integrated care is posited as the answer to many chal- Studies Institute. The Healthcare Improvement Studies
lenges: multimorbidity; implementing new treatment Institute is supported by the Health Foundation - an indepen-
modalities; patient preferences; prevention. For the dent charity committed to bringing about better health and
Five Year Forward View, however, the most pressing healthcare for people in the United Kingdom.
imperative was financial: the need for efficiency savings
in the face of a stagnant NHS budget and increasing ORCID iD
demand.2 Those financial imperatives have carried for- Graham Martin https://orcid.org/0000-0003-1979-7577
ward into the expectations of integrated care systems
and other new care models,4 although evidence that References
they can reduce cost while maintaining quality is
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Health Service Journal 2 August 2019.
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Martin 3

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11. Coleman A, Checkland K, Segar J, et al. Joining it up? Graham Martin
Health and Wellbeing Boards in English local gover- Director of Research, THIS Institute, University of
nance: evidence from clinical commissioning groups and Cambridge, UK
Email: [email protected]