Pete Murphy Nottingham Business School

1. Nottingham Trent UniversityAlternative Futures Conference2013 The Development of Health and Wellbeing Boards in Nottingham and Nottinghamshire Pete Murphy Nottingham Business School Practice Editor International Journal of Emergency Services 13thFebruary 2013

2. Why this may be of interest? • Recent research by ICPSM and EMRU on changing policy and practice in Health and Fire and Rescue services suggests considerable confusion in coalition policy. • A recent cross border multi-agency emergency planning facilitation (with Professor Joyce Liddle) about the financial challenges facing authorities which offered up some practical insights to the confusion (don’t mention region!). • Involvement with the local health economy allows NTU to investigate and contrast both policy and practice. This is about public health and the new Health and Wellbeing Boards not all NHS reforms

3. NHS organisational or structural confusionThe landscape prior to 2010

4. NHS organisational landscape The current chaos

5. Proposed NHS organisational landscape April 2013

6. Health, the NHS Reforms and Health and Wellbeing Board Health - the new landscape Commissioning • Local and General • Public Health • Specialized • Mental Health Education Innovation and Improvement • Deaneries • Local Education and Training Boards • Academic Health Science Networks • NHS Improvement and Innovation Trust Delivery • Acute and Secondary • Primary • Mental Health • Community Services • Dental , Opticians et al Governance and Scrutiny • NHS Commissioning Board Regional and Local Teams. • Clinical Senates • Local Authorities Overview and Scrutiny • Healthwatch

7. Policy confusions - alternative conceptions of politics and public managers explanatory approaches 3 Broad indicative approaches Best seen as a spectrum that ranges from a fairly straightforward relationship of top down influence between politician and public manager to greater reciprocity and complexity in the relationship. • Principal Agent Theory • Public Choice Theory • New Public Service Theory Which one best fits the constitutional environment or situation in which a particular local public service operates – compare China, USA, UK.

8. Principal-Agent Theory • Regards governance structures as simultaneously enabling and constraining the actions of public managers. • Politicians create static and bureaucratic governance structures in a top-down fashion and hold managers accountable for mandated results. • Politicians, as primary drivers of change, ultimately control public managers as agents through constitutional powers such as oversight , appointment, budgeting and legislation. • Democracy takes the form of governance structures that ensure public managers actions reflect the mandates of elected officials.

9. New Public Management or Public Choice Theory • This assumes the need for a more entrepreneurial approach to governance – emulating the responsiveness of the private sector. • Highlights the need for efficient and effective performance, although this can also encompass equity, responsiveness and accountability. • Governance structures are the product of on-going competition and compromise and the public interest is no more than an aggregation of individual self interest. Public managers are not mandated but rather constrained, supported or vetoed by elected representatives through a complex process of negotiation. • However the flexibility can conflict with popular preferences about the provision of services and changing demands of accountability to the public

10. Public Value or Public Service Theory • Drawing on notions of democratic citizenship, community and civil society it focuses on governance with citizens at the centre. • Public managers have to help build a shared notion of public interest, and not merely aggregate individual preferences. • Policies and programmes that effectively meet public needs are achieved through collective and collaborative processes that emphasis the importance of citizens over customers and people over productivity. • Public managers are accountable to a much wider set of demands than just the market or local politicians – but must also respond to “statutory and constitutional law, community values, political norms, professional standards and citizens interests”.

11. What was happening to local public service practise and delivery between 2001 and May 2010? The incorporation of policy and practise based on the concepts of public value. • Setting community-wide outcome orientated objectives at the local level – LPSAs, LAAs, Health and Wellbeing Strategies (inter-agency collaborations to achieve individual and community based outcome objectives) • Evidence based policy and delivery – national and regional observatories, LAA trackers, the development of Joint Strategic Needs Assessments. • Quality assurance – internal and external monitoring and reporting through the performance management regimes of BV, CPA, S4BH, CAA, WCC and CCG and Foundation Trust Authorisations.

12. Key Tipping Points or Developmental Breakthroughs in national policy gradually based upon Public Service Theory • The requirement to achieve Best Value, facilitate continuous improvement and encourage collaborative working (1998 Crime and Disorder Act, 1999 Health Act and 1999 Local Government Act) • Comprehensive Performance Assessments, and Standards for Better Health; the inclusion of the Health “block” in LAA pilots (2003) and the Duty to Cooperate in Community Strategies and LAAs (2007 Act). • Increasing awareness of public health issues, recognition of the World Health Organisation “social” or “wider” determinants of health and the health inequalities agenda (2005 onwards). • The 2008 Quality, Innovation, Productivity and Prevention (QIPP) programme issued by Department of Health to the NHS and the Nicholson Challenge in 2010. • The Health and Social Care Act 2012 NHS reform and Public Health England.

13. The 2012 Health and Social Care ActFrom white paper to enactment An example of theoretical confusion and small ‘p’ politics • From the July 2010 White Paper to the Listening Exercise to the draft Bill and finally to the Act to be implemented in April 2013 • The shifting influence over the agenda – changing fortunes of Alan Lansley and Sir David Nicholson • From new public management in the White paper to new public service theory in the Act • Some key milestones along the journey

14. Health and Wellbeing - Definitions The World Health Organisation (WHO) defines “health” as “a state of complete physical, mental and social wellbeing…not merely the absence of disease or infirmity”. The term quality of life is sometimes used to evaluate the general well-being of individuals and societies. (Quality of life should not be confused with “standard of living”, which is based primarily on income). Standard indicators of the quality of life include not only wealth and employment, but also the built environment, physical and mental health, education, recreation and leisure time, and social belonging.

15. Research Questions What is the potential role of sport and physical activity in the new public health system envisaged by the Health and Social Care Act 2012? • What is the intended or theoretical nature and scope of the Health and Wellbeing Boards within the emerging public health system? • What is the nature and scope of the Health and Wellbeing Boards role in practise as emerging in Nottingham and Nottinghamshire? • What lessons can we draw for future policy and practise?

16. Context - Wider Determinants of Health (Barton & Grant 2006 after Black (1980) Whitehead (1987) Dahlgren, and Whitehead 1991) Acheson (1998) and later Marmot (2010))

17. Key Tipping Points or Developmental Breakthroughs in Health and Social Care • The requirement to achieve Best Value, facilitate continuous improvement and enable collaborative working (1999 Health Act and Local Government Act) • CPA, and Standards for Better Health; inclusion of the Health “block” in LAA pilots (2003) and the Duty to Cooperate in Community Strategies and LAAs (2007 Act). • The increasing awareness of public health issues, the adoption of the World Health Organisation “social” or “wider” determinants of health and the health inequalities agenda (2005 onwards • The 2008 Quality Innovation Productivity and Prevention challenge issued by Department of Health to the NHS and the Nicholson Challenge in 2010. • The Health and Social Care Act 2012 NHS reform and Public Health England.

18. The development of the 2012 Health and Social Care Act • From the White Paper (no mention in the manifesto and no green paper) to the Listening Exercise to the draft Bill and finally to the Act • The shifting influence over the agenda and the changing fortunes of Alan Lansley and Sir David Nicholson • From new public management to new public service theory • Some key milestones

19. Health and Social Care Act 2012 Explanatory Developmental Model

20. Andrew Lansley’s ‘political demise’Some key milestones or political gravestones • Milestone 1 – the Loughborough Bin Man http://www.youtube.com/watch?v=Dl1jPqqTdNo • Milestone 2 – the “pork pie” http://www.ft.com/cms/s/0/d0b2f0f0-450a-11e0-80e7-00144feab49a.html#axzz2KanSzX2X • Milestone 3 – the “LoL” http://www.rcn.org.uk/newsevents/congress/2012/archive_webcast

21. Case StudyWhy Nottingham and Nottinghamshire? • Access to documentation and key stakeholders • Representative? - No but a “core city” and a two tier Local Government area • Potential - Recognised within health community for good practise and innovation - they have both received numerous recent awards e.g. BMJ Clinical Commissioning Group of the Year 2011 - JSNA Good Practise. Early Intervention Nottingham Declaration on Sustainable Development • Active national involvement - Their respective Directors of Public Health had been actively involved in developing the national public health agenda. • Challenging environments - Both “receiving” local authorities had particularly challenging Local Government Finance Settlements • Key Stakeholders -NUHT is 4th largest Acute Trust in the country and Nottinghamshire Healthcare Trust is one of only 3 all-service mental health trusts. • More informally there is a high profile link with Sir David Nicholson CEO of NHS and with the cross party “Early Intervention” agenda of Graham Allen and Ian Duncan Smith

22. What was happening in practice?Nottingham and Nottinghamshire some key findings • Both are “Building not Re-inventing”, complimenting their early adoption of the need for action. • Built upon strong relationships developed between PCTs and LAs in previous LSPs with robust challenge and scrutiny (accountability) allied to mutual respect and individual and collective acceptance of responsibility. • Committed to re-iterative, web based, detailed, substantial and growing evidence bases built around the JSNAs but with open access and multi-agency “ownership”. • Both areas had historically strong recognition and commitment to acknowledging and addressing the wider determinants of health, and have been particularly strong mutual collaborators since the two PCTs were “clustered” with one Board and one Executive team.

23. Findings and Conclusions • Leadership - Health and Wellbeing Boards are a high political priority – both for the councils, for the PCTs and for key health stakeholders e.g. Nottingham Universities Hospital Trust. • Scrutiny – Overlapping and reinforcing internal scrutiny arrangements which are working well (although LINks not prominent) and loss of external scrutiny driver following abolition of Audit Commission. • Opportunities have been missed eg. NHS Transformational budgets and projects , eg the health Innovation and education Cluster (HIEC )– 1 of 24 projects over 3 years was based on physical activity and that was in the final round.

24. Findings and Conclusions • The transfer of responsibility for Public Health and Health and Wellbeing is actually progressing satisfactorily in the case study areas. It is becoming theoretically coherent and pragmatically progressed “on the ground”. • Both individual and collaborative organisational infrastructures are in place or are being developed, although this is being achieved in a less supportive environment than previously existed under Community Strategies/CAA/LAA • This challenge has been exacerbated by the loss of AC, IDeA, and related improvement and innovation infrastructure which has resulted in a significant loss of advocacy, advice, capacity and guidance.