Stakeholder Relations

The context of localism and partnership working in the new NHS in Wales

The Welsh Assembly’s restructuring consultative document on the proposed structural changes to NHS Wales stated that services in the community must be designed to meet varying local needs and be delivered through effective partnership working at a local level. This focus upon local need can only be achieved if the new structures reflect the importance of strong local leadership. The benefits secured to date through the stakeholder model of Local Health Boards must be built upon in the design of new structures. Any model must balance the benefit of fewer statutory organisations, supported by effective engagement and delivery at a local level.

The engagement agenda for the three NHS trusts is a significant one. The trusts are all-Wales bodies who not only have their own local relationships to strengthen and maintain, they also have the added challenge of engaging with the seven LHBs as key stakeholders and with partners and stakeholders across the length and breadth of Wales.

It is recognised that health services, and the organisations which deliver them have boundaries which have to be managed. In the past, organisational boundaries within the NHS in Wales have been seen to inhibit collaborative working.

A significant challenge in building the new NHS will be the creation of a network of organisations, which are effective in delivering within their own areas of responsibility, and creative in working in partnership to deliver broader population benefits across the health system. This commitment to forming a cohesive health system in Wales is of paramount importance. The smaller number of health organisations proposed provides a positive contribution to creating the environment within which such behaviour can flourish.

Principles

The principles to underpin clear local accountability are:

  • a drive for local needs, planning and delivery, but also a recognition that health organisations will need some consistency of services,
  • maintenance of a focus on unitary authority level,
  • a local ability to account for resource decisions within a clear framework,
  • a fresh approach to delivering strengthened local community and primary care services, more closely aligned to social care,
  • building as far as possible on local partnership mechanisms that already exist and to enhance these,
  • an understanding of the relationship with Local Service Boards (LSBs),
  • a clear framework for local accountability, engagement and assurance,
  • a focus upon public health and the health improvement agenda,
  • recognising cross-boundary flows of population,
  • relationships and behaviour that will deliver lasting and long-term change.

Key issues for local partnership relationships

There are three areas to address in respect of the best way to maintain and improve local relationships:

  • Effective planning and delivery – LHBs and NHS trusts must develop and implement plans that ensure that NHS Wales delivers, but also that wherever possible these take place in a local and partnership context;
  • Clear decision-making – LHBs and NHS trusts must make clear decisions on the areas for which they will be held accountable, but also allow this to be achieved in a collaborative manner given the increasing agenda with local stakeholders;
  • Governance and assurance (the barometer test) – the board must have internal assurance of progress within its locality structures, supporting the board, whilst also being subject to external community and partnership scrutiny.

Irrespective of the planning and decision-making processes, the LHBs and NHS trusts must have a clear governance and assurance flow in place to discharge its accountabilities at the formal board level, complemented by the locality focus. The range of responsibilities cannot just be distributed across partnership structures.

Partnership Mechanisms

The NHS has changed over recent years in terms of the extent to which it engages in local partnership infrastructure; this has been a positive development and an area to which existing LHBs have particularly contributed and participated. It is important to recognise the wide range of partnership mechanisms that exist to support local engagement and discussion across stakeholder and communities. Rather than set these aside or introduce new approaches, there is an opportunity to refresh these and incorporate them into a new model for locality focus.

There are already partnership working arrangements in each local authority, and these have a number of relevant qualities:

  • They are usually well established and many are statutory.
  • They involve a range of partners across the public and third sector, and have service user and citizen involvement.
  • There is clear health service engagement formally through membership from and in the LHB.
  • They have in many cases established mechanisms for engaging with more local communities within the local authority area, and seek to reflect their needs in their strategies and service delivery work.
  • They have produced cohesive strategy documents, including Community Plans, Children and Young People’s Plans, Health Social Care and Well-being Strategies, and Community Safety Strategies.
  • They are recognised and valued by partners, service users and citizens generally.

Where local partnerships have been successful they have been based on consistent and senior involvement of NHS colleagues, whether at strategic level, such as the Local Service Boards, whether driving forward Health, Social Care and Well-Being Strategies, or whether contributing to Children and Young People’s Plans and Community Safety Strategies.

The changes to structures must not present barriers to areas which have the leadership and maturity to align local health and social care services in the interest of the citizen’s improved experience.

A key challenge for the seven LHBs will be to develop a mechanism by which they can connect in a meaningful way with communities in the assessment, planning and delivery of health and well-being services, and services for children and young people that meet both national priorities and local need.

This means starting at local community level and building up in an incremental way through well established local authority based partnership working arrangements and the LHB, to ensure the national views and needs of communities are reflected at all levels.

Recognising and enhancing the importance of the partnerships at Local Authority level, it is proposed that the new structures go even further by developing locality arrangements built around natural communities. These arrangements should include primary care and community services working in partnership with social care and the voluntary sector to support the needs of the local population through Locality Networks or partnerships.

The LHBs will actively support and develop the NHS part of the Locality Networks and via this mechanism ensure equity of access to high quality joined-up services at very local level.

This locality model will complement the restructuring of the Community Health Councils and facilitate better clinical and patient engagement at community level.

Stakeholder reference groups
The Minister for Health and Social Services has stated that community engagement and strong partnership working is vital to the operation of an effective NHS in Wales.
 
Stakeholder Reference Groups will be a central piece of the new engagement jigsaw and will provide advice to the LHB board on any issues it considers important to citizens. The Chair of the Stakeholder Reference Group will be an Associate Member of the LHB board, and its membership will ensure involvement in the work of the LHB from a wide range of community based bodies and groups who have an interest in, or involvement with the provision of healthcare.
 

Managing Relationships

Source: Setting the Direction – A Board Member’s Guide – NLIAH/ WAG Publication Edition 4 (05/08)

  • Who are your key partners?
  • What are their key concerns and how do they affect you?
  • What mechanisms will be needed for jointly resolving difficult issues?
  • How does your organisation engage your stakeholders?

NHS organisations operate within a complex network that all have an impact on the health of the individual and the community. A typical ‘patient pathway’ could involve an initial visit to the GP, subsequent visits to the practice to see other health professionals, referral to a specialist consultant in a hospital, treatment as an outpatient and/or inpatient, and discharge from hospital to community nurses or social services support. NHS organisations do not exist in isolation from these other agencies.

Organisations may have many partners, including Health Commission Wales, LHBs and NHS trusts, local authorities, particularly social services, education and housing departments, primary care practices, independent sector providers, the voluntary sector and their managers and staff, public and patients.

The issues and concerns of key stakeholders in the health economy need to be understood and shared and independent and associate members can play an important role in the process. The resources available to deliver all targets across the local health community will be limited. This can lead to tensions, and a key role of independent and associate members will be to liaise with fellow board members and members of local councils to agree a way forward.

Your Role

As board members you have an important ambassadorial role in building strong relationships outside your organisation. The objectives you have agreed with your chair may require you to become involved in:

  • forming direct links with other NHS bodies,
  • networking with local councillors and AMs to share common issues and address local priorities,
  • networking with other agencies, for example voluntary sector and patient organisations, to share their concerns and establish their contributions to addressing local issues,
  • managing relationships with the media.
  • bringing independence to patient issues,
  • informing and being answerable to the public,
  • taking account of the public’s views.

Health Partners

LHBs and NHS trusts are accountable via regional directors to the Director of NHS Wales for the achievement of the NHS Plan and financial targets. However, your organisation needs to work with your own people and with others in your local health and social care community to deliver many of these targets. There may be some tensions between organisations and you can play an important role in helping to resolve any conflicts.

Board members need to gain good knowledge of their local health community partners. Doing so can enable board members to gain an understanding of specific areas of healthcare as well as establishing links with particular organisations. Further advantages can be gained by developing an overview of all the key issues, such as finance, quality and performance, while gaining a better understanding of the organisation concerned.

Voluntary Sector

Your organisation should be contributing to local networks of voluntary organisations, which are focused on users and potential users of services and can provide expertise based on real experience. These are important stakeholders in local health initiatives. A key measure of public service reforms will be the extent to which statutory agencies empower the voluntary sector and allow them to take on wider responsibilities for health and social care.

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