Health and Care Bill 2021: meeting the triple aim duty

In this briefing, we focus in on the “triple aim” to which NHS England, Integrated Care Boards (ICBs), Foundation Trusts (FTs) and NHS Trusts (Trusts) will all be expected to have regard. Values, culture and decision-making arrangements should be built around demonstrating that organisations are individually and collectively focused on the ‘triple aim’ - i.e. the likely effects of decisions relating to:

• The health and well-being of its population;
• The quality of services provided to individuals; and
• Efficiency and sustainability in relation to the use of resources.

Systems must be alive to the fact that changing structures will not in itself change culture or values. To successfully embed the triple aim, systems will need to devote time and resource to aligning values and cultures within and between organisations. Key to this will be senior leaders modelling behaviours that promote the long term wellbeing of patients and communities. Governance arrangements can, of course, be more or less conducive to positive behaviours. Cultural change should therefore go hand in hand with the development of governance, which may need to evolve over time as relationships mature. The Bill provides an opportunity for local systems to shape themselves in response to local needs in a way that has not previously been possible. 

Decision making while having regard to wider impacts and objectives is not unique to the NHS and represents a general trend in society. For example, the Companies Act 2006 (e.g. section 172) requires directors to have regard to the effect their decision might have on various stakeholders and interests.

A positive duty

The triple aim is a positive duty to have regard to the wider effect of decisions - it requires directors to consider the impact of their decisions more widely in respect of various matters.

To meet this duty, we recommend that systems should:

• Use common language - define key aspects e.g. “well-being”
• Use a common approach to achieving the triple aim - what does good look like?
• Develop methodology for measuring success - has the system achieved the triple aim?
• Ensure board assurance frameworks explicitly reference the triple aim
• Ensure that initiatives for collaboration and co-operation are directed towards the triple aim
• Review and where necessary strengthen arrangements for public and clinical engagement so as to understand the perspectives of these groups, given the focus on optimising health, well-being and quality of care

Whilst the current drafting only states that the relevant body must have regard, we recommend that systems report internally on how they are meeting this duty on a routine basis as evidence of compliance. This is not a box-ticking exercise - the Bill itself requires that:

• Before the start of each financial year, ICBs and its partner Trusts and FTs will be required to produce a joint forward plan explaining how the triple aim and a number of other duties will be discharged; and
• ICBs will be required, within their annual report, to report on how they have discharged the triple aim duty.

The arrival of a common duty across NHS bodies does not mean that sovereign boards no longer exist. For example, the duty on FT directors individually and collectively remains to promote “the success of the corporation so as to maximise the benefits for the members of the corporation as a whole and for the public”. FT directors will therefore need to consider what the success of their organisation looks like in a system context. Similarly, the duties on governors remains unchanged. These differing duties will need to be reconciled. In our view, this will be at least as much about winning hearts and minds around to new ways of working as about finding the right form of words to express how these duties fit together. 

Population health

While the triple aim reflects the evolution of corporate governance thinking towards considering the wider impact of organisations, it also embodies the idea of a population health approach. Population health seeks to improve physical and mental health outcomes whilst also promoting well-being and reducing health inequalities across the population of a system.

Population health, as a concept, requires thinking beyond clinical boundaries - e.g. what percentage of the population is employed and do those jobs contribute significantly to their well-being?

A population health management approach is also premised on a deep understanding of the communities which organisations serve. This extends beyond patterns of disease to the wider determinants of health such as the built environment and economic development in local areas. In most systems, the characteristics of the communities served will differ from place to place and sometimes on a neighbourhood basis. Areas as small as the Wirral contain some of the most deprived, but also some of the least deprived, communities in England. As a system, there will need to be an understanding of the differences between the various places to ensure that the whole system strategy for population health accounts for these differences and seeks to address inequalities.

To achieve the level of understanding required, it will be crucial to gather, curate and share the right data. Data will need to be adaptable and translatable into insights that can be used by system partners.

As systems ready themselves to operate on a statutory basis, they should consider how well they know their local communities, both in terms of needs and preferences as well as the community assets that can support health and well-being. They will also need to carry on a dialogue with their communities about how data can be gathered and used to local benefit. A consistent approach to this conversation by all organisations within the system will be essential to securing community support. 

A system which does not prioritise a population health approach may struggle to show that it has the knowledge of the communities it serves that is necessary to meet the triple aim. Over the next few months local health and care leaders will need to focus on structural change. This should not be at the expense of reducing community and stakeholder engagement. The most effective systems are those whose plans and structures are built on a clear understanding of the needs and expectations of the communities they service.

Knowledge of communities and their needs must shape system plans. As local health and care leaders are increasingly focused on structural change, they will not want to lose sight of the need to stay engaged with their communities.

How can we help?

• Practical advice on values and behaviours that will drive system change
• Developing governance structures which are proportionate and where form follows function
• Sharing our experiences of successful public and patient engagement
• Devising information governance strategies which support population health management