Accountable Care Health and Social Care Public Health

The role of multi agency boards in complex environments 

Like all areas in the universe, we are busy working out what “Accountable Care” actually means.

The ACP “Board” like other “grand boards” (inc HWBB) will have responsibility of “transforming stuff” in a context where individual organisations are still sovereign.

In various guises I’ve been giving a bit of thought to big “partnership boards” and our ask of them. Immediate thoughts below. I don’t profess to know “the answer” just have a few thoughts. It’s clear there’s no neat pithy answer so has to be built

1 What do we want our ACP Board to “do” 

We may want the ACP Board to be many things, but it is definitely not run the organisations within a partnership operationally.

‘Transform things’, is the general answer to the q of what we want partnership boards to do.

“Transforming” is not “improving things”, it is “fundamentally redefining the job and the mission, then improving things”.

A counter view to this is to not accept that transformation is ever “done”, or a completed project. By itself, transformation is necessary, but as means not end. Probably what we want the ACP Board to do is “oversee delivery of an equitably healthy population” or something like that, with transformation as a critical component.

Another counter view is that we should expect such boards to improve business as usual in a way that can’t be achieved by individual organisations working along. In general we do BAU quite well in our various silos. However this isn’t universally agreed on. There are some areas we may NOT to BAU well, and we may do BAU well in the interests of our silo or organisation but not in the best interests of the population or city as a whole. Maybe it depends on how we define silos. there are some tricky business and sticky points within BAU. But as well there ARE some things we want to make a difference in. This should be the space of the ACP board. The ACP may usefully draw out what outcomes each org is trying to deliver in BAU and how this relates to overall outcome AND overall agreed system principles. Someone suggested recently an audit of what the givens, red lines and statutory responsibilities are – agree 100%.

Some thoughts on what we might want such a board to do in a transforming things context:

* Create and hold us to common incentive structure and similar.

* Develop the narrative around a common mission – what is it that we are supposed to be accountable for, to whom, at what level.

* Create common culture…. I accept I need to define better what I mean here, but it’s a dealbreaker. Something around all orgs see the world in same way, see mission in same way, act in a way consistent with the mission.

* Agree common £ strategy. HOW we use the ££ we have, investments and disinvestments.

* Commission OD – As system, not orgs focused on the mission

* common principles – as per stuff already done. I’d also add something along lines of

* Each org within the system as a whole needs to be responsible and accountable for their aspect of the system performance.

* Agreed that “it’s a system” shouldn’t be a reason to mask poor performance of one org within the system.

* Each org needs to be responsible for its own data and performance. And share this transparently.

* And maybe something on lines of  purchasing power, economic anchor institution local $ and local economy
there are some clues from available literature on areas it may be good that the ACP focuses in a transformation context.

for example P51 of this WHO document on multi sector governance is very useful (a bit obvious, but useful starting framework

The Kings Fund also publish helpfully in this space (see below)

What teeth do partnership boards have.

There doesn’t seem to be a collected body of wisdom or research on how we give those boards actual teeth to get change done. Of course “grand partnership boards” are often suggested as toothless talking shops and not as “something that controls the agenda” or “shapes it”.

As a bare minimum we should expect something around positive influence over a complex system in a complex environment.

Many would say that all multi organisation “boards” wont / cant have teeth – unless they REALLY control the cash. Do they need “teeth”. If it doesn’t have “teeth” most then say it’s a talking shop – the classic name for grand partnership boards.

Are “teeth” actually control of the resources, or control or influence over how the system operates, the rules, the mission.

So role of such boards is to 1) set common rule structure 2) agree common investment programme 3) agree common narrative and shared principles, and ensure all orgs have same interpretation of the mission and are able to hold each other to account for it.

Some might suggest that realistically – meaningful control of resources by ACP board will only be granted by central government – voluntary arrangements can work but will always be vulnerable to one org taking their ball home. So without this the best teeth we can hope for are a culture of mutual dependency, cooperation and holding to account, centred on a collectively owned vision. In this context the Board IS the teeth.

Soft influence might look like

  •  “how do the discussions at the board influence the strategy, give all partners a better collective and system understanding of an area, and understand the points of influence and inflection from the lens of all of the different constituent parts”
  • There is something around different partners holding each other to account (whatever that means) in public and private. So for example – when was the last time organisation A held B to account for xxxx or vice versa for yyyy. How does this work across multiple organisations
  • Maybe the acid test is the question of when was the last time a conversation at HWBB actually influenced the resource commitment profile, strategy or policy or investment / disinvestment of one or more of the constituent orgs… what was the line of sight.
  • Single unifying mission/goal/vision is critical from my point of view – and not sure how close we are to agreeing this. Suspect the world looks very different from organisation xxx and yyy points of view – and funding/ constitutional arrangements obviously contribute to the mission,

What does an ‘effective Board’ look like

A few have picked me up on the effectiveness of HWBB of late….along lines of ineffective talking shops etc. Often folk say these things are talking shops…. to which my response is talk is is ok if the alternative is not talk, as long as we’re talking about the right stuff.

My standard response is to ask the questioner the question back – “what does ‘effective’ looks like”
There is the ever present challenge of getting into the gritty detail of services vs a role of multi sector boards around a broader shape agenda – exerting influence in complex environment…. it’s ever harder to measure ‘effective’ in that space.

I have an ever present fear that if we delve into detailed focus on “stuff” we may 1) never come out of the rabbit hole and 2) inevitably get sucked into the gravitational pull of health care services, and the detail of one sector not a multitude of sectors – health vs health care etc.

On effectiveness of multi sector boards, and making them effective
Maybe something to be said about Ideas sponsorship, what are the high level, and details level ideas that we develop.

Right mix of
programme oversight
Specific detail on services and projects
Strategy development
Strategy implement
Performance review

Mark Gamsu suggested some helpful indicators this afternoon

  • Diversity of voices – or the usual players
  • Scope. Is it clear. NHS & Social care delivery or Health & Well Being
  • Where does challenge to change come from, how powerful is the voice of change.
  • Investment in process to develop new public voices. Panel or forum, deliberative process to develop voices and mechanism to get fresh voices into the room.

2 People and behaviour vs contract and organisational governance

The Kings Fund recently published a synthesis of learning on leading across organisations. It’s excellent

Leading across the health and care system | The King’s Fund

Key messages

The paper details five factors that facilitate system leadership:

* develop a shared vision and purpose: this requires a shift from a reactive problem-solving mindset to creating a positive vision of the future built around the needs of local populations

* have frequent personal contact: face-to-face meetings enable leaders to build rapport and understanding and to appreciate and acknowledge each other’s problems and challenges

* surface and resolve conflicts: this depends on leaders’ ability to recognise conflicts, work them through and create the conditions in which it is safe to challenge

* behave altruistically towards each other: to work together in a collaborative way, leaders need to move away from a traditionally competitive style and to focus on the bigger picture

* commit to working together for the longer term: leaders need to invest time and energy in forming effective long-term relationships and to resist the pressure to focus on the immediate, transactional issues.

In a relatively short number of sides, in simple clear language, this sets out the key elements of “partnership” that a thousand pages of governance guff and legalese contracts will never get close to.’

There is nothing new in this, however, we all know that it always boils down to people and not structures; a common sense of mission; shared principles and wider than individual organisational self interest. This document reinforces and plays well into the people not structures, language and narrative type of discourse rather than complex discussions about contracts and organisations.

Of course, shifting the culture, powerbase (and resource base) from one part to another may require more than fancy language, but it does need to be written down and agreed – but if its not written down it wont happen etc

As ever, being clear about the mission and problem we are trying to solve is something I come back to time and time again. We obviously need to continually reflect on WHAT we are accountable for, and to WHO, and at what level.

I feel we often under-invest in these kind of discussions. Too often people develop visions outside boards for presentation and agreement – we need the ACP Board to own the vision, which will come if they develop it themselves. This is not a quick job by any stretch. And involves hard conversations if it is to be meaningful.

We must think about how to bring workforce and public/service users into such a conversation too – the former definitely need to buy into any vision too, and the latter maybe do as well (see: Wigan Deal. It’s a pre requitiste. Something needs developing about getting mandate and ownership of our owners, customers, users, patients

More practically, proposed purpose early on could be:

1. What is our job, role (below may help)

2. What’s the expectation of other stakeholders (national and local)

3. What IS our mission – collective mission (again refining the below might help, as might getting our clear and unequivocal principles straight). Is the mission better health or better health care. Of course it’s both, but what’s the balance.

4. What big things are in flight (the usual list of  suspect programmes, can be described through BCF or similar)

5. What’s missing – the big transformative pieces – Im working on my list, but will include

* payment reform,

* overdiagnosis –wasted resource on grand scale.

* population systems of care for segments of pop – agnostic of service provider.

* primary care at scale – …. This is a dealbreaker for me.

* focusing on disease (or event) incidence not prevalence – if we only ever manage  prevalent disease…we miss the real value opportunity – ie prevent stuff!

6. What are the things we REALLY want to change…. For me – 

* big shift of resource away from hospital / episode centric to non hospital / population centric – measurable in ££££,

* redressing inquality in GP and primary care resourcing,

* local ownership of delivery system and democratic accountability.

All of these things are easy to say.  Who does what at what level

* HWBB, ACP Board, Ch Exec, level down, etc etc

* likely director level group of all our orgs to push it on…..

* programme office stuff…..

Principles – some suggestions

We all agree we need a common set of shared principles. Mine are as follows


I’d start with outcomes – the goal is healthy (healthier?) population, equitably distributed – everything flows from this. Single unifying mission/goal/vision is critical from my point of view – and not sure how close we are to agreeing this. 

The world looks very different from different stakeholders (not just organisations) points of view – and funding/ constitutional arrangements obviously contribute to this.


Resource in the NHS should be distributed according to population need, and disproportionately distributed to reflect disproportionate need.

Resourcing should be focused on outcomes, not service activity or flow

Addresses problem of providers do not need to address need, but demand, and heath service, particularly where most of the resource is, is funded according to demand, not need.

Also addresses problem of inequity of resource allocation


Neighbourhoods and primary care – defined widely and broadly – is the building block from which we should start

Investment is needed in primary care and social care. A 2% shift of resource from hospital to primary care buys 9% increase in GP resource. Or about 8-10% increase in GP consultation capacity. That can readily be linked to outcomes.
Focus on community building and strengths based community approach.


Services should be provided to meet the needs of segmented chunks of population, defined by population need and agnostic of service provider.

Shape of segments to be considered

Personally I would shape around population focused issues rather than service oriented segments


Person centred

Person centred, goes without saying (or should) but need some careful definition and unpacking as it’s not universally agreed on. Wigan Deal / Strengths based approach sort of stuff….


Agreement of the principal causes of cost growth – disease incidence (under investment in prevention), over diagnosis (cultural and system driven), low value technology, multimorbid population and fail of demand management side.  It is NOT the ageing population.


Conflict. no org will unilaterally take a decision that disadvantages another? Does this need unpacking a little more?

How we handle scenario where the legal and financial responsibility of an individual organisation is in conflict with the system as a whole or other orgs within the partnership.

Addressing this in principle before the rubber hits the road will help. A lot.

8)How do we share risk and benefit

how does this risk and benefit share reflect the mission.


Something about purchasing power, economic anchor institution local $ and local economy

I’ll come back to this one,

Only my random views 

You may have better ideas 

Be keen to see them

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