Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from Clinical Commissioning Groups and Shadow Health and Wellbeing Boards

Statutory responsibility for health care and social care has long been separated between National Health Service (NHS) bodies and local government authorities. Repeated policy attempts to promote service integration through collaboration between such authorities have achieved little. The latest of such policy interventions are the Health and Wellbeing Boards (HWBs) established by the 2012 Health and Social Care Act (HSCA) alongside a range of other organisational innovations, including Clinical Commissioning Groups (CCGs). These organisations await full legal and operational status but have begun to develop structures and processes. HWBs are intended to lead the integrated assessment of local needs to inform both NHS health and local authority social care commissioners. We undertook detailed qualitative case studies in eight CCGs during 2011–2012 and here report observational and interview data related to CCGs’ perspectives and observations of early HWB developments. We found that developing HWBs vary greatly in their structure and approach, but we also identified a number of significant issues that are familiar from earlier research into health and social care integration. These include heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.     

CUSTOMER CARE AND THE PUBLIC SERVICE ETHOS

The Labour governments that have been in power in the UK since 1997 have reconceptualized the public service ethos. In an apparent departure from their Conservative predecessors, Labour ministers have argued that the distinctive culture of public service can enhance rather than impede service quality and deliver high levels of customer care. This article utilizes interviews and content analysis data to explore the ethical dimension of public service, the significance of the language of customer in relation to ethos, and the implications for service delivery of a customer care focus. Case study findings show that a customer orientation is endorsed by politicians and bureaucrats in both central and local government, although there is a lack of clarity about the service manifestations of such a shift in emphasis. Respondents voiced concerns about the viability of customer care in the public sector as well as the sidelining of the political role of citizen.     

Notes on Contributors

Social services departments have been an integral feature of local authorities in England for delivering social services since 1970 with a distinct identity, a largely uniform set of social service functions and similar organisational structure. This model of a unified social services department has survived major structural reorganisations in local government, the community care initiatives and social services modernisation agendas. This paper reviews recent government initiatives to promote closer collaboration between health and social services and identifies the different models now in place or being put into place. These include formal partnerships, integrated management, integrated care trusts and the example of fully integrated health and social services trusts. The paper considers whether such developments along with the establishment of new children's trusts will finally mean the disintegration of local authority social services departments, whether the Seebohm vision has been abandoned and what future there is for social care within local government.     

Health and Local Government Partnerships: The Local Government Policy Context

This article explores partnerships between health and local government from the local government perspective; placing developments between the two sectors within the wider context of the Local Government Modernisation agenda. A number of commentators have argued that developments since 1997 – in particular the emphasis on community leadership and the new power of well-being – have provided local authorities with an exciting opportunity to reclaim a more pivotal role in shaping the health agenda at the local level. Such a role would be based on promoting well-being and a good quality of life, in keeping with the social model of health. In the longer run this reclaimed role could produce a shift in what has become the main boundary between health and local government: the health–social care boundary. The article reviews developments in three key areas: the health–social care boundary; the core components of the Local Government Modernisation Agenda; and the relationship between regeneration and health. The paper concludes that although progress has been made in regeneration and health and there is potential in elements of the Modernisation Agenda that these do not equate to a paradigm shift in local government's perspective on health. Instead, the social care boundary continues to dominate local government's vision of health. Central to this picture of modest progress is the substantial barrier to more radical change provided by the performance management frameworks governing both sectors.     

Public participation

’Evidence‐based practice’ is a term used in Britain's National Health Service to describe the use of research evidence in policy, management and practice decisions. This article develops this idea and explores its use in local government decision making, using case studies of social care and education. It argues that the absence of a funding stream to support local authorities’ own research reinforces a view of local authorities as essentially administrative arms of the state, supervised through service‐by‐service performance measurement, rather than ‘intelligent’ agents using local research to develop evidence‐based policies.     

Transformational Government? The role of information technology in delivering citizen-centric local public services

Following on from five years of ‘electronic government’, the Labour Government has recently announced a new five year plan for ‘transformational government’. Like its predecessor, t-government emphasises the important role of information technology in enabling the delivery of modernised public services. Modernisation is defined as an increasing emphasis on citizen choice, personalisation of services and understanding and responding to service user needs. This paper explores the appropriateness of the t-government agenda by drawing upon lessons learned from the preceding e-government era. Arguably the most significant citizen-focused technology of the e-government era was customer relationship management. The potential of CRM to support service transformation is explored and co-production, an alternative approach to citizen-centric service design, is examined both as a way of addressing weaknesses in IT-enabled service transformation and as a candidate later stage in the evolution of citizen-centric local public services.     

What Drives For-Profit and Nonprofit Organizations’ Entry into Voucher Markets?

This study investigates a social service voucher program in Korea to examine why local governments rely on external actors, such as for-profit and nonprofit organizations, in provisioning social services and what encourages such market entry in view of the transaction cost theory. The social service voucher program, first introduced in 2007, offers a unique dataset of 1,101 local markets to examine how local governments are willing to stay in control of provisioning the nationwide program while promoting private actor entry. This study finds that local governments with lower fiscal capacities or in markets in which multiple existing organizations operate are more motivated to foster for-profit entry, whereas only existing nonprofit organizations in the market that provide the same services predict nonprofit entry. The implication is that the facilitation of for-profit entry is associated with local governments’ need to manage transaction costs, although this may not be true for nonprofit entry.     

'Out Of Sight, Out Of Mind': Assessing The Impact Of Markets For Children's Residential Care

This article is concerned with assessing the effectiveness of markets for complex professional services in social care. The issue is explored through an account of developments in the children's residential care sector. Over the past five years there has been a steady expansion in the role of external markets in this area. However, this was not required by the Children Act 1989 and has become the subject of considerable debate between policy makers and practitioners. While some favour an extension of choice, others argue that a further decline in local authority run provision will be both costly and detrimental in terms of meeting key policy goals. In order to assess these claims, reference is made to the findings of a study of purchasing practices for children's residential care in twelve local authorities in England and Wales. The impact of the emerging market is analysed along two dimensions. Firstly, we assess how far it is operating efficiently, concentrating on market structure, information and transaction costs. Secondly, attention is given to the impact of market changes on the policy objectives of: localized placements; ensuring adequate safeguards; and matching needs and services. The results reveal that there have been significant costs associated with markets in children's services. In a context of government efforts to promote modes of service delivery on the basis of 'what works', these difficulties have certain implications. Not only do they draw attention to the need for greater collaboration between purchasers and providers, they also point to the continued relevance and usefulness of local authority managed provision.     

PUBLIC EXPENDITURE AND POLICY IMPLEMENTATION: THE CASE OF COMMUNITY CARE

This article explores the contention that the conventions of public expenditure accounting conceal, rather than reveal, the real nature and implications of resource trends. A benchmark — a constant level of service output — is established as a basis for examining the relationship between trends in expenditure inputs and service outputs. Changes in unit costs are identified as the major source of deviation between expenditure and output trends. The impact of resource constraint on policy and policy-implementation is then examined in relation to one, essentially stable, area of policy in the personal social services: community care.
The meaning of the term'policy' is far from straightforward and community care is best understood as the interaction of relatively independent streams of policy, towards service outputs and resource inputs, extant in both central and local government. Mechanisms by which policy streams could be reconciled are of particular interest and an innovative example — joint finance — is examined in some detail.     

Tackling society's “detritus”: Stakeholder partnerships and Urban service delivery in India

In view of the emerging debate on a coordinated‐management perspective for resolving development improvidence, there is now a broadening of the scope of decentralization, emphasising not only vertical restructuring of powers and resources but also analogous horizontal restructuring at the local level to include collaborators outside the government arena. Grounded on this perspective, the present paper examines the process of stakeholder partnerships in urban service delivery, especially on urban environment maintenance service through refuse collection and disposal. The paper is reflective in nature, drawing on a case study of solid waste management processes in Bangalore, India. It examines the characteristic of stakeholder partnership in the delivery of public services, draws insights into the enabling environment and thereupon attempts to identify future interventions to strengthen the delivery of public municipal services. The paper argues that much more needs to be understood if institutional pluralism in local government is to become an effective development strategy.     

Transformation in Philippine local government

This research examined the challenges, enablers and outcomes of organisation transformation in Philippine local governments. We combined a multi-case study research design and backward mapping approach in collecting and analysing narratives from 55 leaders in 9 Filipino local government units (LGUs) that have successfully undergone transformation. Results show that the transformations of the LGUs appear to have been catalysed by three interrelated elements: vision, LGU leadership and citizen engagement. The transformation in the local governments concentrated on multiple foci of reform including structure and systems improvement, culture change, human-resource development as well as policy and programme development. This holistic approach enabled the transformation of bureaucratic and unprofessional government service to transparent, professional and efficient public service that engendered pride, transparency and social equity. Implications of the proposed model for transforming LGUs and in developing LGU leaders for good governance are discussed.     

Sustainability reporting by Australian local government authorities

This qualitative study investigates the Western Australian (WA) local government authorities’ sustainability reporting practices, in the absence of mandatory reporting guidelines, through content analysis of their websites. Calculations from comparing the Global Reporting Initiative (GRI)’s disclosures with those of 140 local council websites were used to develop a sustainability reporting disclosure index. The findings indicate that sustainability reporting remains moderately practised by local government authorities, despite stakeholder demand for proactive disclosures. The discourse analysis shows that Western Australia’s strategic planning for sustainable development is the key force propelling councils towards sustainability reporting practices. The findings also suggest that WA local government authorities are increasing sustainability disclosures to legitimate their social and environmental initiatives. The findings have policy implications for regulators and/or government in Western Australia, with practical implications for local council authorities and/or managers in developing awareness of sustainable operations. The study also contributes to local government authorities’ growing awareness of sustainable service operations.     

Raising wages in the controlled sector: A comment on Elliott

This case study from Eastern Zambia challenges the thesis that after independence an elite of privileged farmers entrenched itself through domination of the local political arena and a coalition with the civil service. It argues that such a view may be a reification due to misplaced assumptions about historical continuity and the uniformity of social behaviour; a lack of attention to the actual operation of government departments at the lowest levels; and neglect of how people construct ways of life on the basis of different interpretations of the world.     

External Constraints on Local Service Standards: The Case of Comprehensive Performance Assessment in English Local Government

Central government in the UK has introduced performance management regimes that apply rewards and sanctions to local service providers. These regimes assume that organizational performance is attributable to decisions made by local policy-makers rather than circumstances beyond their control. We test this assumption by developing a statistical model of external constraints on service standards and applying this model to the outcomes of comprehensive performance assessment (CPA) in English local government. The results show that CPA scores were significantly influenced by the characteristics – such as social diversity and economic prosperity – of local populations. Thus 'poor' performance is partly attributable to difficult circumstances rather than bad choices.     

Strategic competence and agency: individuals overcoming barriers to change in South African higher education

Social relations, institutional arrangements and cultures bequeathed by South Africa’s system of apartheid continue be felt in the present despite the country’s formal transition to democracy 25 years ago. Race, class and gender inequities continue to structure South African society in ways that have proven intransigent to change, leading to growing frustration and widespread public dissatisfaction expressed in multiple arenas including worker strikes, service delivery and university student protests. While it is clear that social structures inherited from the past are difficult to change, it is also the case that change does happen. In this paper, we discuss the findings of a hermeneutic phenomenological study with 10 academics at one historically White university in South Africa, who have been agents of change within their particular context. We show how participants engaged in struggles to counter resistance to their efforts. In doing so they demonstrate what we call ‘strategic competence’ – the ability to act in ways that not only draw on personal resources but recognise the resources, contradictions and opportunities offered within the existing limitations of the social structure. Strategic competence thus emerges as a central feature of agency, enabling individuals to stretch the boundaries of what is possible.     

‘She's Like a Daughter to Me’: Insights into Care,Work and Kinship from Rural Russia

This article draws on ethnographic research into a state-funded homecare service in rural Russia. The article discusses intersections between care, work and kinship in the relationships between homecare workers and their elderly wards and explores the ways in which references to kinship, as a means of authenticating paid care and explaining its emotional content, reinforce public and private oppositions while doing little to relieve the tensions and conflicts of care work. The discussion brings together detailed empirical insights into local ideologies and practices as a way of generating new theoretical perspectives, which will be of relevance beyond the particular context of study.     

Investing or Squandering Social Capital? Community-Based Organizations for Indigent Health Care

Abstract

Externally funded collaboratives are compared in a US–Mexico border location, focusing on the local commitments that are made in financial and social capital for long-term sustainability. The border offers special challenges to sustainable health care programs, given the substantial crossing that occurs among health care users in both North-to-South and South-to-North directions. Funding organizations that decentralize programs to community collaboratives, demanding considerable local leverage and in-kind contributions, create a pernicious tax on poor communities in the name of building community capacity. Despite good intentions, precious community social capital is squandered.     

The Contracting Quandary: Managing Local Authority–VNPO Relations

Problems with competitive transactional contracting raise the possibility of relational contracting as an attractive alternative for managing local authority–VNPO (voluntary non-profit organisation) relations. This empirical study of 45 relational social service contracts examines the conditions under which advantages such as flexibility and social capital development emerge as opposed to dangers of political abuse, defiance and resource frustrations. Findings suggest that successful relational contracting requires partners whose professional and management reputations inspire competence trust and whose commitment encourages goodwill trust. Decisions between competitive transactional contracting and relational contracting present difficult dilemmas. The costs and benefits of relational contracting need to be weighed against those of transactional contracting. At the same time there are political and ideological pressures, as well as public service norm constraints.     

Russian Nonprofits as Contracted Providers of Municipal Social Services: Initial Experience

Abstract

In the Russian Federation the delivery of social services to deserving population groups is mostly the responsibility of municipalities and other local governments. Services are delivered by municipal agencies. One way to inject competition into the delivery system is for local government to hold competitions to contract for social service delivery. The competitions can be open to nonprofit organizations (NPOs), some of which have been providing assistance in recent years to needy individuals and families similar to those that would be contracted. This article reports the results of an assessment of pioneering pilot competitions for the delivery of social services in three municipalities in 2000–2001: Perm, Velikii Novgorod, and Tomsk. The objective of the pilots was to determine if the local governments could hire NPOs to be service providers following a rigorous and fair competitive process and whether the selected NPOs would do an adequate job in delivering services. In general the results of these competitions indicate the extent of the challenge to improving service delivery in Russia. It seems fair to say that the competitions in Perm and Tomsk were essentially a competitive grant process where the winners were more or less free to determine the services actually delivered. On the other hand, the Novgorod competition had much more in common with a contractual procurement of social services—the competition was nominally open to firms of all legal forms and the services were well-defined. In execution, the reality in Novgorod fell far short of this model.     

The Social Shaping of Participatory Spaces: Evidence from Community Development in Southern Thailand

Critical analysis of participatory community development has claimed that such approaches serve as a vehicle for social control and co-option by external actors. Drawing on a case study from Southern Thailand, this article argues that we need to take a less deterministic perspective, and pay more attention to the ways in which community members themselves manipulate or subvert participatory processes. The article shows how this may result in hybrid participatory practices and institutions that contain elements of both local and external interests, and which play a key role in defining the way power is constituted in local participatory spaces.