Enhancing democratic accountability in health and social care: The role of reform and performance information in Health and Wellbeing Boards

• DOI: http://doi.org/10.1111/faam.12216
• Date: 01 November 2019
• Published date: 01 November 2019

Received: 28 February2018 Revised: 1 March 2019 Accepted:5 August 2019

DOI: 10.1111/faam.12216

ORIGINAL ARTICLE

Enhancing democratic accountability in health and

social care: The role of reform and performance

information in Health and Wellbeing Boards

Suzana Grubnic1Stuart Cooper2

1School of Business and Economics,

LoughboroughUniversity, Loughborough, UK

2Department of Accounting and Finance, School

of Economics, Finance & Management, University

of Bristol, Bristol, UK

Correspondence

SuzanaGrubnic, School of Business and Eco-

nomics,Loughborough University, Loughborough,

Leicestershire,LE11 3TU, UK.

Email:s.grubnic@lboro.ac.uk

Fundinginformation

CharteredInstitute of Management Accountants,

Grant/AwardNumber: R517

Abstract

The UK government passed the Health and Social Care Act in

2012, and a key element of this legislation was the introduction of

Health and Wellbeing Boards (HWBs) in local government. HWBs

were argued to have the potential to both improve democratic

accountability and give greater autonomy to health and social care

leaders to strengthen local health outcomes. This paper explores

how members of HWBs construct and discharge accountability for

better health outcomes to a local population. We find that there

are multiple types of accountability present and that democratic

accountability can be complemented by and compete with other

types of accountability.

KEYWORDS

accountability, Health and Wellbeing Boards, New Public Gover-

nance, performance, reforms

1INTRODUCTION

The mission and objectives of organisations responsible for providing public services are multiple and ambiguous,

conflicting and imprecise, contradictory and confusing and are often associated with issues of equity and fairness

(Christensen & Lægreid, 2015; Parker & Gould, 1999; Sinclair, 1995). Public services, therefore, require multi-

dimensional and multiple accountabilities that are “continuallybeing constructed” (Sinclair, 1995, p. 231) and shift with

frequent reforms (Bracci, Humphrey,Moll, & Steccolini, 2015).

The increasing multiplicity and complexity of public service provision has led governments to replace New Pub-

lic Management (NPM) with New Public Governance arrangements, which involve broader societal actors and part-

ners to achieve their desired outcomes (Klijn, 2008; Osborne, 2006). In their conceptual paper, Virtanen, Stenvall,

Kinder, and Hatam (2018) consider how accountability arrangementsdiffer between the more hierarchical structure

and efficiency focus within NPM to a more processual “flow within an integratedlocal service system” (p. 2) within New

Public Governance. A change to New Public Governance emphasises integratingand coordinating networks of actors

(Christensen & Lægreid, 2015, p. 213) and results in new accountability arrangements (Valentinov, 2011; Virtanen

Financial Acc & Man. 2019;35:353–372. wileyonlinelibrary.com/journal/faam c

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354 GRUBNIC ANDCOOPER

et al., 2018), which are in addition to those that were already in place (Benish & Levi-Faur,2012). There is a danger that

these new arrangements will lead to shared accountabilities and tangled accountability arrangements (Christensen &

Lægreid, 2015).

Within this context, the study explores the creation of Health and Wellbeing Boards (HWBs) in local government

in England. The introduction of HWBs was a keyelement of the UK Government’s Health and Social Care Act in 2012,

which places a statutory requirement on all upper-tier and unitary local authorities in England to establish a board and

treat the board as if appointed under section 102 of the Local Government Act 1972 (Local GovernmentAssociation,

2013). It was argued that implementing the Act would improve democratic accountability and givegreater autonomy

to health and social care leaders to strengthen local health outcomes. It is an example of the coalition government’s

attempts to “replace the old system of bureaucratic accountability with a new system of democratic accountability—

accountability to the people, not the government machine” (Cameron, 2010). A keyelement of Cameron’s democratic

accountability was to provide transparencyto the people through publishing full information, giving people choice and

democratic control through local elections and local referenda (Cameron, 2010).

HWBswere expected to bring together key players (as a statutory minimum, membership of the boards is comprised

of elected councillors, senior local government officers representing adult social care and children’s services, public

health officials, clinical commissioners, and Healthwatch, as a body representing the local community) with a range

of insights into the care and safeguarding of the local population. HWBs also have the option of co-opting additional

memberssuch as the police, firebrigade, and universities if it is felt that the key post-holders could help co-developnew

solutions. In order to work toward better outcomes for the public, the LocalGovernment Association (2013) clarified a

number of principles underlying the creation of the boards, including shared leadership of a strategicapproach, shared

ownership, and parity between board members on deliberations, strategies, and activities.

Improving the health and wellbeing of people in a given area, and reducing inequalities, is aided by the statutory

duties of the boards. Specifically, the Health and Social Care Act 2012 requires local authorities and clinical commis-

sioning groups (who have replaced primary caretrusts) to develop a Joint Strategic Needs Assessment (JSNA) (assess-

ing the needs of the local population) and a Joint Health and Wellbeing Strategy (JHWS) (an overarching strategy).

In developing their strategies, HWBs are required to consider the role of wider social determinants such as housing,

education and transport on health, wellbeing and quality of life. In order to fulfil the requirements of openness and

transparency, the preparation of the JSNA and JHWS is to involvemembers of the local public and for the finalised

documents to be published. The HWBs are accountable to both full council and the local public and could be called to

account bythe local authority’s overview and scrutiny function (OSF). In addition to the JSNA and JHWS, HWBs should

also provide clear measures of progress on priorities that havebeen agreed by board members.

Thereis very limited research that explores accountability relationships in the context of a recent shift towards New

Public Governance. More specifically,a gap remains regarding how this shift effects the types of accountability expe-

rienced in the various relationships between the network of New Public Governance actors. This paper contributes

to the accountability literature by exploring how members of HWBs construct and discharge accountability and how

the members perceive interactions between different accountability types. The significance of this contribution is due

to the broad range of accountability types and relationships that are present and interact within our case HWBs.

Specifically, our paper contributes further insight into how different accountabilities may compete with and comple-

ment each other.We also explore how the UK Government’s Health and Social Care reform has changed accountabil-

ity arrangements, both accountability relationships and types, and how performance measurement informs the prac-

tices in our case HWBs. As such our paper responds to Christensen and Lægreid’s (2015, p. 223) call for research that

studies

the dynamic relationships between reforms, performance and accountability and how multiple and hybrid

accountability relations interactand change over time.