Feature

Alliances or dalliances?

‘Partnerships’ between the NHS, local authorities and other bodies are proliferating—but their accountability is often minimal, says Fiona Campbell

In the NHS and local government, partnerships are everywhere. Most discussion concentrates on how partnership working can deliver better, more ‘seamless’ services to users. This is not surprising, given that passionate advocacy from the grassroots for more joined-up services combined with government pressure has provided the impetus for new partnerships.

But now questions are being asked about their governance arrangements. Do they meet the governance standards for single organisations in health and social care? Are they robust enough to support good decision making?

Proper accountability of partnerships matters because the public in general, and those affected by the decisions taken, have a right to know:

• who is responsible for the effective and efficient use of public money;
• who is taking decisions and how the public can influence them;
• who is responsible if things go wrong;
• what accessible forms of redress there are.

With the Children’s Bill paving the way for yet more partnerships in the form of children’s trusts, this is a good time to reflect just where all this is taking local accountability.

Towards a typology of partnerships – a whole new discipline?

In the health and well-being arena there are now various types of partnership.

Trusts with a ‘partnership’ aspect

Their budgets come from different sectors and their titles and governance arrangements reflect this to a greater or lesser degree. It is a moot question whether, although officially described as partnerships, they are really so in anything but name. For example, care trusts are NHS bodies, usually primary care trusts with some social care functions.

And, as Bob Hudson points out, councillors on care trust boards ‘are formally there to contribute on a personal basis, not as local authority representatives’.¹

Similarly, mental health partnership trusts are usually just NHS mental health trusts with a new name, operating section 31 budget-pooling arrangements with local authorities. The government’s partnership rhetoric can obscure the fact that one sector has much greater control over decision making and that accountability is minimal.

Such partnerships may mean closer working but they often make for unclear governance and accountability. Steve Bundred, the new chief executive of the Audit Commission, has claimed that for every pooling of resources, there is a corresponding halving of accountability.²

Local Strategic Partnerships

These supposedly mediate cross-sectoral cooperation on a huge range of issues, within the framework of an overall community strategy. They have a wide variety of members representing (in a very loose sense) a set of local ‘stakeholders’. NHS trusts and PCTs are encouraged by the Department of Health to see LSPs as key players in developing and even implementing health inequalities strategies.

Some LSPs are chaired by elected representatives, but others are chaired by unelected representatives of local bodies, such as the principal of a local further education college or a business leader. Individuals end up on the boards of LSPs through a variety of routes. Some LSPs are genuinely involved in decision making around the development and implementation of community strategies. In such cases, it is often unclear where ultimate accountability rests for decisions taken. In other areas, there are stories of a completely different group of people being present at successive board meetings, depending on which individuals happen to be available.

In these cases, the locus of accountability, both collectively and back to the separate organisations represented, is hopelessly muddled.

Statutory partnerships bringing together stakeholders to tackle specific issues

Examples of these would be early years partnerships and crime and disorder reduction partnerships. In these types of partnerships collective accountability may be clearer in relation to matters such as achieving national targets. But lines of accountability to local ‘partner’ organisations may be much less clear. For example, how many PCT boards receive regular reports from their ‘representatives’ on crime and disorder reduction partnerships?

Health partnership boards

In some areas, these boards are trying to provide a forum for cross-sectoral discussion of health issues. Some will receive, comment and contribute to drafts of PCTs’ local delivery plans. Others will be used as a convenient forum for the NHS’s new statutory duty to consult (section 11, Health and Social Care Act 2001).

As such, they may be indicative of an all-too-understandable tendency of statutory bodies to pursue consultation and involvement through bureaucratic forms more suited to the needs of the consulter than the consultee.

In many local health forums there is considerable confusion between patient/user and public involvement, engagement and consultation on the one hand, and decision making, accountability and democratic responsiveness on the other.

NSF partnership boards

These relate to the different NHS national service frameworks, for example older people’s partnership boards. They are often used as a sounding board for the work of a local implementation team relating to each NSF.

Like the more general health partnership boards, NSF boards can provide a genuine opportunity to seek and listen to the views of service users and those most closely affected, such as carers. But there is little clarity about whether they are also decision-making bodies and, if so, to whom or to which organisations they are accountable.

There is also a danger of tokenism in offering ‘community’ places on decision-making bodies. You can influence a meeting much more if you know the background, if you are experienced in the rules of engagement for such meetings and have had time to read the papers. Presumably this is partly why unelected non-executive directors of NHS trusts and PCTs with no representative function are paid more than £5,000 a year for this role.

But a representative of a pensioners’ forum sitting on an older people’s partnership board gets expenses at most. Is this because the work of the board is considered to be less valuable or because the people involved are valued less? Probably both: in any case, support to enable genuine and representative participation and a level playing field for board members is a pressing issue.

Local community partnerships

These were set up to take forward specific time-limited projects, such as regeneration projects with a health component or capital projects to set up healthy living centres. In cases such as these, budgets and the direction of policy have often been decided elsewhere and neighbourhood organisations and individuals come together to discuss the detail of implementation.

Paradoxically, it is often these partnerships with a very focused remit that hold themselves most answerable to local people and find ways of ensuring that they have a say in detailed decisions.

Overall, it looks as though partnerships are here to stay and it would be wrong to suggest that we should draw back from them where they are genuinely delivering better services (although in some cases, even this is disputed).³ So what can be done to dissolve some of the lack of transparency about partnerships’ accountability?

The box lists some suggestions, which may not apply equally to all types of partnership (for example, it might be too much to expect a small neighbourhood project to meet all the conditions). They won’t guarantee success, but they should make for greater clarity — and that is a large part of what accountability is about.