Health and Wellbeing Board maturity matrix rationale

It is structured in four parts:

• Part one sets out the overall design logic: the relationship to the PCH framework, the scoring model, and the principles applied across all domains. 
• Parts two through four work through each domain in detail: its rationale and origins, its relationship to adjacent domains, and the thinking behind each level descriptor.

Summary of key design decisions

The matrix retains the PCH seven-component structure  but makes four substantive changes.

• Population health and wellbeing and inequalities becomes its own domain. This minimises the chance that a board can articulate a population health and wellbeing and wellbeing purpose without that purpose ever driving decisions; separating the domain means a board cannot score well overall without demonstrating that evidence genuinely drives decisions, not just documents.
• Community and VCSE engagement becomes its own domain. Boards with strong NHS relationships frequently have weak or absent community engagement. If both sit within partnership working, a board can score well on ICB relationships while having no meaningful community voice. 
• Leadership is distributed across two domains rather than given its own. This picks up the argument that HWB leadership will fail if it is seen as the responsibility of one person. If leadership is a collective and emergent property, it is better tested through shared purpose (domain 1) and relational trust (domain 4) than as a separable domain in its own right.
• Neighbourhood health is added as a new domain. This responds to the nw duties and goes beyond statutory compliance: its ceiling requires boards to be building the conditions for community resilience and co-governance, not simply leading an NHS-compliant plan. 

The separation of domains 5 and 6

Both domains address communities. Domain 5 asks how communities inform the board's own decisions (the input function). Domain 6 asks what the board is building so that communities can take greater control of their own health and wellbeing (the output function). These are different questions with different evidence, and a board can score well on one while scoring poorly on the other. The domain 6 ceiling opens with a single defining test: are communities measurably more capable, better connected and more in control as a result of the board's leadership?

The scoring model

A 1 to 5 scale with floor and ceiling anchor descriptors was chosen over three labelled levels for three reasons: the label "developing" is experienced as a verdict; a score allows a board to locate itself between states and track movement over time; and a total out of 35 enables longitudinal self-assessment. A fully populated five-by-five grid was rejected because the Scottish Approach to Service Design demonstrates that grid density inhibits the facilitated conversation the tool is designed to support.

The principle holding all descriptors together

Every descriptor is grounded in observable behaviour rather than aspiration. Self-assessment works better when anchored in things people can point to than in things they believe about themselves. Domains 3, 4 and 7 each include an explicit population health and wellbeing and wellbeing test so that high scores on structural and relational domains cannot be achieved by boards whose purpose has narrowed to managing NHS demand. 

Starting point: the PCH framework

PCHs own draft guidance, "HWB top tips slides v.2 DRAFT" provides the primary structural scaffold for the matrix. It organises board effectiveness across seven components: legislation and policy; purpose and focus; making a difference; partnership working; leadership; capacity and resourcing; and governance. This framework is grounded, developed with direct knowledge of how boards function, and captures the essential distinction between boards that operate as strategic partnerships and those that function as council committees.

The maturity matrix retains seven domains and preserves the substance of each component. It does not discard or contradict the PCH framework. But the architecture has been revised in four respects: two components are separated into distinct domains (purpose and focus becomes purpose/leadership and population health and wellbeing and wellbeing/JSNA); one PCH component is substantially widened (governance becomes neighbourhood health, place-based leadership and community resilience); and one PCH component is redistributed rather than given its own domain (leadership is folded into purpose and shared leadership, and into partnership working). The reasons for each of these choices are set out below.

The four structural revisions and why they were made

Separating population health and wellbeing and wellbeing and inequalities from purpose and focus. In the PCH framework, population health and wellbeing and wellbeing and inequalities appear within "purpose and focus" as one element of what an effective board is trying to achieve. In practice, this arrangement means a board can engage genuinely with questions of purpose and focus without ever substantially grappling with health inequalities as a driver. The JSNA can be referenced in the strategy without visibly shaping priorities. The inequalities agenda can be named without being operationalised.

This is not a theoretical risk. 

The March 2026 neighbourhood health framework makes the same point from a statutory direction: it requires HWBs to ensure neighbourhood health plans are informed by the JSNA, which only matters if the JSNA is genuinely active. Giving population health and wellbeing and wellbeing and inequalities its own domain means a board cannot score highly overall without demonstrating that evidence is driving decisions, not just informing documents.

Separating community and Voluntary, Community, Faith and Social Enterprise (VCFSE) engagement from partnership working. The PCH framework treats partnership working as a single domain covering relationships with all partners, from the ICB to community groups. In practice, board-to-board partnership tends to be more developed than community and VCFSE engagement. Collapsing them allows a board to score well on ICB relationships while having no meaningful community voice. 

Adding neighbourhood health, place-based leadership and community resilience as a distinct domain. The PCH framework does not include a neighbourhood health domain, having been developed before the March 2026 neighbourhood health framework made HWB leadership of neighbourhood health planning a statutory expectation. The new domain is warranted on two grounds. 

First, it reflects the statutory landscape: 

Second, and more importantly, the domain goes beyond the statutory minimum. Drawing on PCH's own collaborative community approach model, the domain's ceiling asks not whether a board has led the neighbourhood health plan but whether it is building the structural conditions through which communities can take greater control of the factors that affect their health and wellbeing. This is a more ambitious and more important test, and one PCH is uniquely placed to articulate.

Distributing leadership rather than giving it its own domain. The PCH framework treats leadership as a standalone component. The maturity matrix treats it as a property distributed across two domains: domain 1 (purpose and shared leadership) and domain 4 (partnership working). This reflects a specific claim about what effective leadership in an HWB context actually means: it is not a property of the chair, nor even primarily of individual members, but of the collective. 

Giving leadership its own domain would risk treating it as an observable property of individual behaviour rather than as an emergent property of how the board works together.

The scoring model: why 1 to 5 with anchor descriptors

A scored scale with two anchor descriptors was chosen over the alternatives for three distinct reasons.

First, it removes the problem of the "developing" label. A three-level model with labels such as "developing," "effective" and "leading" presents boards at the lower end of the scale with a word that may be experienced as a verdict rather than a starting point. A score of 1 or 2 communicates the same diagnostic information without the same sting, and a board that scores 2 on purpose and 4 on partnership working can hold both pieces of information at once without either becoming defining.

Second, it reflects how boards actually develop. Real development does not happen in clean discrete jumps between labelled stages. A board can be genuinely between two states, and a score allows it to say so and to track its own movement over time. The anchor descriptors give the self-assessment conversation a shape to work within while the score allows the board to locate its own position within that shape.

Third, a score out of 5 per domain produces a total out of 35 that is useful for tracking progress over time. This is a deliberate departure from the Scottish Approach to Service

Design, which does not aggregate across dimensions. The justification for the departure is the HWB tool's emphasis on longitudinal self-assessment: boards should be able to return to the tool after a development programme or after a change of leadership and see whether and in which domains they have moved.

The level labels: the contribution of the Scottish Approach to Service Design

The five level labels used alongside the numeric scale are drawn directly from the Scottish Approach to Service Design (Scottish Government Digital Directorate, 2019). That framework uses not evident, limited, growing, strengthening and embedded as its five maturity levels across all five of its dimensions. The labels are well-designed: they are non-judgmental, they convey direction rather than verdict, and they map cleanly onto a 1 to 5 numeric scale.

The Scottish framework writes a full behavioural descriptor for every level of every dimension.

The HWB matrix takes a more accessible approach, using floor and ceiling anchor descriptors only, with a brief navigational note at level 3. 

The Scottish framework does not aggregate scores across dimensions. The HWB matrix does. The reason is different use context: the Scottish tool is primarily a design audit; the

HWB tool is primarily a longitudinal self-assessment. 

The principle of observable behaviour throughout

Every descriptor in the matrix is grounded in observable behaviour rather than aspiration or attitude. This matters for two reasons. 

First, self-assessment works better when it is anchored in things people can point to rather than things they believe about themselves: "the board has changed its commissioning approach in response to what communities said, and members can name a specific example" is a more reliable self-assessment anchor than "the board values community input." 

Second, observable descriptors are more honest: they do not allow a board to score itself at ceiling level on the basis of good intentions.

The floor descriptors are written to be honest and recognisable. They describe real boards doing real things: they are not worst-case scenarios or deficit frames. 

Domain 1: purpose and shared leadership

Origin in the PCH framework. This domain draws primarily on the "purpose and focus" component (slide 6) and its "leadership" component (slides 9 and 10). 

From purpose and focus: the call for a "shared and agreed understanding of the role of the HWB and what it is trying to achieve," the emphasis on "clarity about purpose including the need to drive hard on wider determinants of health," and the imperative of having "a clear narrative about role and priorities as a strategic partnership." 

From leadership: the distinction between option A (committed individual leaders with passion and vision) and option B (collaborative leadership as "a team sport"), with PCH explicitly preferring the latter. The Institute of Collaborative Leadership framing on slide 10 is the primary reference for the ceiling descriptor, particularly the behaviours listed for a board "being led in a collaborative fashion": passion for the cause, active management of the tension between action and relationship-building, courage to act for the long term, and the ability to share knowledge, power and credit.

The separation of leadership from its own domain. The decision to absorb leadership into domain 1 rather than giving it a standalone domain reflects a specific interpretive choice about what effective HWB leadership means. The PCH's own slide on collaborative leadership argues that "leadership will fail if it is seen as the responsibility of one person" and is "more likely to thrive if it is seen as a team sport." If leadership is fundamentally a collective and distributed property, it is better understood as an emergent quality of how the board holds its purpose (domain 1) and how its relationships function (domain 4) than as a separable domain with its own floor and ceiling.

Why "committee vs partnership" is the domain's founding tension. The distinction between a board that functions as a council committee and one that functions as a strategic partnership is named explicitly in PCH's "key statements" slide: "effective HWBs operate as strategic partnerships, not council committees." 

A board that has not resolved this tension does not know what kind of body it is, and that uncertainty pervades everything else: how members understand their role, how the agenda is shaped, whether challenge is possible, whether members act between meetings. Domain 1 holds the identity and culture question; domain 7 holds the governance mechanics that either serve or subvert that identity.

Domain 2: population health and wellbeing and wellbeing, inequalities and the JSNA

Origin in the PCH framework. This domain draws on the "purpose and focus" component (where the JSNA is named as a fundamental reference point) and the "making a difference" component (which calls for "data-led decision making with the JSNA as a fundamental reference point in decision making"). The primary question, whether the board drives its work from an actively used understanding of its population's needs, combines PCH's emphasis on the JSNA as a reference for strategic decision-making with the March 2026 neighbourhood health framework's explicit requirement that neighbourhood health plans are informed by the JSNA.

The deliberate exclusion of the DPH from the primary test. DPH capacity, resource and positional authority vary enormously across local authorities and are only partially within the board's control. A board that has excellent population health and wellbeing and wellbeing intelligence embedded in its work but a DPH who is, for structural reasons, a relatively junior voice at the table should not be penalised. 

And more fundamentally, population health and wellbeing and wellbeing intelligence embedded in board culture is more important and durable than any single individual's influence. The domain consistently asks what the board does with intelligence, rather than who delivers it.

Domain 3: strategy and impact

Origin in the PCH framework. This domain corresponds most directly to the "making a difference" component (slide 7). The PCH slide makes several points that directly inform the domain's design. It argues that boards should be able to "confidently articulate what difference the HWB will make in relation to each priority." It introduces the "reality check" framework: distinguishing what is fundamental (cannot be changed), negotiable (can be influenced with effort) and controllable (within the board's own capacity to act). It calls for "a small number of metrics related to the priorities" against which the board should review its effectiveness regularly.

The domain's emphasis on accountability for strategy delivery, and particularly the claim that every member should be able to articulate their organisation's contribution to each priority, also draws on PCH's accountability framework from the "partnership working" section: individual HWB members accountable for their own contribution, constituent organisations accountable for their organisational contribution, and the collective board accountable for overall impact.

The distinction from domain 2. Domain 2 asks whether the board uses intelligence to drive decisions. Domain 3 asks whether the resulting decisions are focused and whether the board can demonstrate they made a difference. The cleanest test of this distinction: a board could have rigorous JSNA-informed analysis (high domain 2) but a strategy that attempts too many things and cannot demonstrate impact on any of them (low domain 3). Equally, a board could have a focused, accountable strategy (high domain 3) but one that was not informed by a strong population intelligence base (low domain 2). The domains test different questions that are related but not identical.

The metrics cross-reference. The domain 2 and domain 3 ceilings both reference a small set of agreed measures. The explicit design decision, reflected in both descriptors, is that these should be the same set: the JSNA-derived population outcome measures should be the same measures the board uses to track its strategy progress. This prevents the disconnected situation where a board has a set of population health and wellbeing and wellbeing indicators and a separate set of strategy KPIs that are rarely placed in conversation with each other.

Domain 4: partnership working and relationships

Origin in the PCH framework. This domain corresponds to PCH's "partnership working" component (slide 8). The PCH slide identifies several mechanisms that distinguish functional from dysfunctional partnership: open and trusting relationships; clarity about differences and similarities; recognition that tensions must sometimes be acknowledged and managed rather than resolved; an open learning culture; and building ways to offer and receive constructive challenge without damaging relationships. The PCH is explicit that accountability should operate at three levels: individual member contribution, organisational contribution, and collective board accountability for overall impact.

The domain also draws on PCH's "additional information" section on HWBs' role in the ICS, particularly the diagnostic questions: "do you have a track record as a driver of integration?", "are you strategic, working with neighbours to join up?", "do your HWBs demonstrate inclusive leadership with other system leaders including providers, police and crime commissioners, community and voluntary sector?" These questions help calibrate what ceiling-level partnership working looks like in the current policy context.

The explicit separation from domain 5. The decision to make the VCFSE sector the exclusive territory of domain 5 required domain 4 to be explicitly scoped to statutory and organisational partners. The primary question was revised from the earlier formulation to include "key statutory and organisational partners." The ceiling descriptor includes a bridging sentence:

The board's strong statutory partnerships actively create space for, rather than crowd out, the community and VCFSE engagement that is addressed in domain 5." 

This is important because a board at ceiling level on domain 4 might otherwise appear to have all the partnership relationships it needs, when in practice the domain's scope does not include the community and VCFSE relationships that domain 5 tests.

Why the VCFSE is not a partner in domain 4's terms. The deliberate decision to treat the VCFSE as the subject of domain 5 rather than domain 4 reflects a specific observation about how boards tend to develop. 

Boards that have good NHS and statutory partner relationships frequently have weak or absent VCFSE and community engagement. If both are in domain 4, a board that scores 4 or 5 on ICB relationships but 1 or 2 on VCFSE engagement will still score well in the domain overall. 

Domain 5: engagement with communities and the VCFSE

As above explains, this “forces the VCFSE engagement gap to be visible.” In addition it also responds to the new guidance that observes effective implementation of neighbourhood health includes “working in partnership with communities (including people and carers* with lived experience and local third sector organisations) to co-develop neighbourhood health locally, and to mobilise change.”

The domain's design also draws on the PCH collaborative community approach model, which articulates the distinction between commissioning services for communities and building community capacity; and the Scottish Approach to Service Design's principle of "designing with, not for," which maps directly onto the ceiling descriptor's claim that community members are involved in defining problems rather than only responding to proposed solutions.

The input/output distinction underlying the separation from domain 6. The most important structural relationship in the domain architecture is the distinction between domains 5 and 6. The design principle is as follows. Domain 5 asks about the board's input function: how does it hear from and act with communities in shaping its own decisions? Domain 6 asks about the board's output function: what structural conditions is it creating in neighbourhoods that enable communities to take greater control? The first is about how communities inform and shape the board; the second is about what the board's leadership is building for communities. Both are necessary; neither is a subset of the other; and a board can be at very different levels on the two.

A practical illustration: a board might engage communities excellently in framing its JSNA priorities (high domain 5) while having no systematic approach to building neighbourhood infrastructure (low domain 6). Equally, a board might be actively building neighbourhood health infrastructure through ICB-led processes (moderate domain 6) while having no community representation at its own table (low domain 5). The separation makes these combinations visible and diagnostically useful.

The commissioning culture dimension. One of the domain's most distinctive contributions isits explicit attention to commissioning culture. The competitive tendering of VCFSE services is named in the floor descriptor as an observable indicator of a board that has not considered how its commissioning decisions affect the sector's capacity to work collectively. 

The collaborative community approach model makes the same point explicitly. Including commissioning culture as a domain indicator makes the point that community and VCFSE engagement is not only a question of who attends the board: it is also a question of how the board's commissioning creates or destroys the conditions for collective VCFSE capacity.

Domain 6: neighbourhood health, place-based leadership and community resilience

The statutory landscape has changed: HWBs are now expected to lead neighbourhood health planning. 

A domain that asks whether the board is building community resilience and co-governance infrastructure, rather than simply whether it is compliant with NHS neighbourhood health requirements, is the primary tool the matrix has for holding that tension.

The floor descriptor and the 2027 to 2028 risk. The floor descriptor for this domain is written to describe a recognisable present-day situation rather than a worst-case scenario: a board that receives neighbourhood health presentations from its ICB and endorses the resulting plan. This is, at the time of writing, a common pattern. It is important to note that from 2027 to 2028 this pattern will represent a failure to meet the board's statutory obligations, not merely a maturity gap. 

PCH may wish to flag this in the tool's introduction, to signal that the floor of this domain is a transitional and increasingly untenable position rather than a stable starting point.

The ceiling's defining test. The domain 6 ceiling opens with the question that all other evidence in the descriptor is intended to illuminate: whether communities are measurably more capable, better connected and more in control of the factors that affect their health and wellbeing as a result of the board's leadership. This test was chosen because it is the most complete single description of what success in this domain looks like, and because it resists being reduced to NHS delivery metrics. A board could lead a technically compliant neighbourhood health plan while communities remain essentially passive recipients of redesigned services. The defining test ensures this does not count as a ceiling-level outcome.

Domain 7: governance, capacity and ways of working

Origin in the PCH framework. This domain draws directly on two components: "governance" (slide 12) and "capacity and resourcing" (slide 11). From governance: the diagnostic questions about whether the board has a distinctive role, whether agendas and focus are considered holistically, whether there is excessive demand for papers and presentations that do not result in action, and whether council constitutions are inhibiting honest strategic conversation. From capacity and resourcing: the consideration of forward planning, ways of working beyond formal meetings, the distinction between engagement in public meetings and meaningful engagement with communities, and the practical questions about officer support, papers, and member capacity.

The PCH's own emphasis in this area is well-aligned with the domain's design. The governance slide notes that "HWBs fail when they behave like committees of council" and sets out a specific list of diagnostic questions about whether governance arrangements make best use of partners' time and resources. The capacity slide makes the crucial observation that "form follows function": governance arrangements should be shaped by what the board is trying to do, not by inherited committee conventions.

The relationship to domain 1. The distinction between domains 1 and 7 is the distinction between culture and structure. Domain 1 asks: does the board know why it exists and does it hold that purpose collectively? Domain 7 asks: are the practical conditions, meeting design, paper quality, officer support and membership, built to serve that purpose? The two domains are closely related, and a board that scores 1 on domain 1 will almost certainly also score 1 on domain 7. But they can diverge in interesting ways: a board might have developed a genuine shared sense of purpose (domain 1 score 3 or 4) but still have governance arrangements that work against it, perhaps because committee norms are deeply embedded in the council's constitution (domain 7 score 2). Identifying this divergence is diagnostically useful because it tells the board's development story more precisely than either score alone.

The practical test for allocation of evidence between the two domains: would this behaviour change even if the board's culture were right? If yes, it belongs to domain 7. Agenda design that defaults to report-heavy formats would persist even if members had a strong shared sense of purpose, unless someone actively redesigns it: this is domain 7. A board whose members do not use their organisational influence between meetings because they have not agreed what they are trying to achieve collectively: this is domain 1.

The public accountability note. The domain 7 floor descriptor includes a reference to the constraining effect of formal public meetings on candid strategic conversation. The PCH's own governance slide observes that "council constitutions" can inhibit "honest strategic partnership conversations, debate, disagreements." The description frames public accountability as a feature of HWB governance that requires active design rather than as an inherent problem: a board at ceiling level has "considered how to create appropriate space for candid strategic conversation while fully meeting its public accountability obligations." This framing acknowledges both the constraint and the design challenge without implying that transparency is in tension with effectiveness.

The following sets out the specific design choices made to maintain clean boundaries between domains that are closely related. For each significant boundary, the rationale for the separation and the practical tests applied to maintain it are described.

Domains 1 and 7: culture vs structure

The boundary. Domain 1 owns the board's culture, identity and self-understanding. Domain 7 owns the structural and practical conditions that enable or constrain that culture. The boundary is maintained by asking: "would this behaviour change even if the board's culture were right?" If yes, it belongs to domain 7 (it is a structural question); if no, it belongs to domain 1 (it is a cultural question).

How the boundary is maintained in the descriptors. Domain 1's floor describes members attending as organisational representatives, not acting as advocates between meetings, and having no shared narrative. These are cultural and identity failures. Domain 7's floor describes long agendas, report-dense meetings, and clerking-only officer support. These are structural failures. 

Why the boundary matters. A board that has addressed its culture but not its structure, or vice versa, has a clearly identifiable development need that a blurred boundary would obscure. Identifying both independently helps boards understand what kind of development work they need: cultural development (facilitation, development sessions, leadership coaching) is different from structural development (governance review, agenda redesign, officer capacity).

Domains 1 and 4: purpose-based vs relationship-based leadership

The boundary. Both domains describe distributed leadership, but from different angles. In domain 1, leadership is distributed because members have internalised a shared purpose and act on it independently. In domain 4, leadership is distributed because the trust and relational infrastructure makes collective accountability possible. The distinction is between the motivation to lead (domain 1) and the relational conditions that sustain it (domain 4).

How the boundary is maintained in the descriptors. An earlier draft of both ceilings contained near-identical language about distributed leadership. The revision ensures that domain 1's ceiling grounds distributed leadership in the board's shared story and intrinsic motivation ("a strong and shared sense of what only this board can do"), while domain 4's ceiling grounds it in relational accountability ("sufficiently strong and trusting to enable genuine collective accountability... members challenge each other constructively... and accept challenge in return"). These are different things and they can diverge: a board with a strong shared sense of purpose but poor interpersonal trust will have domain 1 strength and domain 4 weakness.

Domains 2 and 3: intelligence use vs strategic accountability

The boundary. Domain 2 asks how the board engages with and is challenged by population intelligence. Domain 3 asks whether the resulting strategy is focused and whether the board can demonstrate impact. The distinction is between the quality of the evidence base and the engagement with it (domain 2) and the focus, ownership and demonstrability of the strategy that results (domain 3).

How the boundary is maintained in the descriptors. Domain 2 focuses on whether the JSNA is live and used, whether health inequalities are a genuine challenge function, and whether population intelligence is embedded in how the board is serviced. Domain 3 focuses on whether the board's strategy is focused (not a list of everyone's priorities), whether accountability for delivery is clear, and whether outcomes can be demonstrated. Both domains reference a small set of agreed measures; the design decision was to specify explicitly that these should be the same measures, preventing the situation where accountability for population health and wellbeing and wellbeing and accountability for the strategy become disconnected exercises.

Domains 2 and 6: strategic intelligence vs neighbourhood-level application

The boundary. Domain 2 addresses the JSNA as a strategic intelligence function for the board's entire work. Domain 6 addresses the JSNA as a specific input to neighbourhood health planning. This is a whole-to-part relationship rather than an overlap: domain 6's JSNA references are a specific application of the broader domain 2 principle.

How the boundary is maintained in the descriptors. Domain 6's ceiling does not reproduce domain 2's language about the JSNA. Instead, it refers to "the board's JSNA-informed population health and wellbeing priorities" as a known quantity, treating them as established through domain 2 and applied in domain 6. The neighbourhood health framework's explicit requirement that neighbourhood health plans be informed by the JSNA is noted in domain 6 as a specific statutory application, not as a restatement of the general principle.

Domains 3 and 4: strategy framework vs relational accountability

The boundary. Domain 3 asks whether the board has a focused strategy with clear collective accountability for delivery. Domain 4 asks whether the relationships between members are strong enough to make that accountability operational. The distinction: domain 3 is about whether the framework exists; domain 4 is about whether the trust makes it real.

How the boundary is maintained in the descriptors. Domain 3's floor describes the absence of a small number of board-owned priorities with clear collective accountability. Domain 4's floor describes the absence of the relational conditions (trust, candour, constructive challenge) that would make any such framework operational. A board could score 4 on domain 3 (clear, focused, accountable strategy) and 2 on domain 4 (partners polite but not trusting enough to challenge delivery failure), which is a different and identifiable development problem from the reverse.

Domains 4 and 5: statutory partners vs communities and the VCFSE

The boundary. Domain 4 addresses relationships with statutory and organisational partners: NHS, council, public health, police, housing, education. Domain 5 addresses engagement with communities and the VCFSE. The separation is explicit in the domain 4 primary question, which now specifies "key statutory and organisational partners."

Why this separation is essential. Peer review evidence makes the case for this separation directly. A board can maintain reasonable working relationships with its statutory and NHS partners while having no VCFSE representation, a fragmented VCFSE sector, and communities who feel entirely uninvolved in the board's priorities. If community and VCFSE engagement is contained within partnership working, a board in this position can score 3 or 4 on partnership working overall, obscuring the gap. Domain 5 as a separate domain makes that gap visible and requires it to be scored independently.

The bridging sentence. The domain 4 ceiling includes the sentence: "the board's strong statutory partnerships actively create space for, rather than crowd out, the community and VCFSE engagement that is addressed in domain 5." This is not just a cross-reference; it is a substantive point. Strong statutory partnerships that are pursued without attention to the board's relationship with communities and the VCFSE can inadvertently crowd out that engagement by consuming the board's relational energy and creating a culture of professional governance that communities find inaccessible.

Domains 5 and 6: community voice as input vs community capability as output

The boundary. This is the most important boundary in the architecture. 

Domain 5 asks: how does the board hear from and act with communities as an input to its own decision-making? 

Domain 6 asks: what structural conditions is the board creating in neighbourhoods that enable communities to take greater control of their own health and wellbeing? 

The distinction is between communities as participants in the board's own processes (domain 5) and communities as the beneficiaries of the board's place-based leadership (domain 6).

How the boundary is maintained despite the inherent relationship. 

Domain 5's ceiling asks: is community intelligence actively shaping the board's own decisions? Can the board name specific priorities that changed in response to what communities said? Is the commissioning culture enabling VCFSE collaboration rather than fragmenting it? 

Domain 6's ceiling asks: are communities measurably more capable, better connected and more in control? Is the board producing neighbourhood infrastructure as a structural outcome? The domain 6 ceiling opens with the defining test about community capability and control, which is a different question from domain 5's test about community voice in the boardroom.

A board could score 4 on domain 5 (strong community engagement in board-level decisions) and 2 on domain 6 (limited actual neighbourhood infrastructure), or vice versa. Identifying this divergence provides a more precise development story than a single combined domain would.

Design principles applied across all descriptors

Floor descriptors are honest about what boards actually look like. They are written to be recognisable to a board at the lower end of the scale without being punishing or making value judgements about the board's intentions. The floor is a starting point, not a verdict. 

Ceiling descriptors are grounded in evidence from real boards. They are not theoretical ideals. Calderdale provides the primary ceiling-level case study evidence across several domains, and is referenced explicitly where its observable practices are relevant.

Score 3 navigational notes describe movement, not arrival. They are intentionally brief (no more than three sentences) and describe what a board in the middle of the scale is doing, not what it has achieved. The purpose is to give boards that score themselves at 2 or 3 a sense of direction rather than a fixed description to match against.

All descriptors ground their tests in population health and wellbeing outcomes. Domains 3, 4 and 7 are most at risk of being scored well by a board with a primarily NHS-framed purpose. Each includes at least one explicit reference to population health and wellbeing outcomes or health inequalities as the purpose the domain is in service of, ensuring that high scores on these domains cannot be achieved by a board whose focus has narrowed to NHS demand management.

Domain 1: descriptor rationale

Floor rationale. The floor describes a board that understands its role primarily in terms of statutory compliance: producing the JSNA, publishing the strategy, and managing the committee business. This is the evidence base from PCH's own diagnostic questions (slide 2): "do members of the HWB struggle to describe what it does and how it makes a difference beyond statutory responsibilities?", "does it operate like a council committee?" The floor does not attribute blame or suggest the board is failing; it describes a board at the beginning of a development journey that many boards are at.

The floor focuses on culture: why members attend, how they understand their role, whether there is a shared story. It does not describe governance mechanics (those belong to domain 7). The key indicator in the floor is the answer to the question: "what does this board do that could not happen without it?" A board at score 1 cannot answer this question consistently.

Score 3 note rationale. The note describes a board that has articulated its distinctive role and is beginning to use it. The emphasis on "articulated" rather than "demonstrated" signals that this is an early stage of development: the shared story exists but is not yet embedded in how members operate between meetings.

Ceiling rationale. The ceiling is structured around three claims, each of which is observable. First: every member can describe the board's purpose consistently. Second: leadership is genuinely distributed, with members acting as system leaders between meetings. Third: the board's purpose is explicitly grounded in population health and wellbeing and wellbeing, not only in managing the NHS interface. The third claim was added at the second revision to address the critique that domains 1, 3 and 7 could be scored highly by a board with a primarily NHS-framed purpose. Calderdale is the primary evidence base: a board with a long-term population vision (Vision 34), strong public health leadership at board level, and a DPH confident enough to present the board's work at national conferences.

Domain 2: descriptor rationale

Floor rationale. The floor describes the pattern observed in peer review evidence: a JSNA produced on schedule, a strategy that references it, but neither document visibly shaping decisions. The key diagnostic test is whether health inequalities are interrogated as a challenge function or merely named as a concern. A board at score 1 measures its performance in terms of activity and process rather than population outcomes. This is the gap between compliance and effectiveness that this domain is specifically designed to surface.
Score 3 note rationale. The note describes a board that is connecting intelligence to at least some of its priority discussions and is naming health inequalities as a driver. The qualifier "not yet consistent across all areas" is important: a score 3 board is not yet doing this systematically, but there are genuine examples of intelligence driving discussion.

Ceiling rationale. The ceiling focuses on what the board does with intelligence rather than who delivers it. An earlier draft named the DPH as the primary indicator; this was revised to focus on the board's practice. The ceiling makes a specific structural claim: that the population outcome measures the board tracks are the same measures it uses to assess strategic progress. This prevents the disconnection between health intelligence work and accountability for strategy delivery that is observable in some boards. The evidence base includes Calderdale, where the DPH plays an active strategic challenge function, but this is presented as one example rather than as the test itself.

Domain 3: descriptor rationale

Floor rationale. The floor describes a board with an unfocused strategy and no clear accountability. The "controllable/negotiable/fundamental" framework from PCH's "making a difference" slide is the direct reference for the floor's claim that the board has not applied a test to distinguish what it can change from what it cannot. The absence of board-owned priorities, as distinct from a collection of all partners' priorities, is the key observable indicator.

Score 3 note rationale. The note describes a board that has done the hard work of narrowing its priorities and is beginning to have honest conversations about the limits of its influence. The phrase "beginning to have honest conversations about the limits of its influence" is specific to the controllable/negotiable/fundamental framework: a board at score 3 is starting to apply this test, even if it has not yet completed the work.

Ceiling rationale. The ceiling asks for specific, measurable changes attributable to the board's leadership. The test of attribution ("that would not have happened without the board's orchestration") is deliberately demanding because it is the most reliable way of distinguishing strategic impact from coincidence. The evidence base was changed from Torbay (which is better placed in domain 6, where the 86% diversion statistic is an illustration of place-based infrastructure outcomes rather than strategic accountability) to Calderdale, where Vision 34 provides a stable long-term anchor against which annual strategy progress can be assessed.

The ceiling explicitly tests whether the strategy is working for the populations experiencing the worst outcomes, not only for the system as a whole.

Domain 4: descriptor rationale

Floor rationale. The floor describes a board where relationships are formal, where the council-ICB relationship is dominant and others are thin, and where tensions are managed through politeness rather than addressed directly. The PCH partnership working slide's emphasis on "building ways to offer and receive constructive challenge without damaging relationships" is the direct reference for this gap: a board at score 1 has not built this capacity.

Score 3 note rationale. The note was substantially shortened from the first draft, which described a board where honest exchange was already occurring and where members were using their influence between meetings. The revised note describes an earlier state: emerging shared language and some honest exchange beginning to occur. A board where acknowledgement of delivery failure is genuinely possible has already moved considerably beyond score 3.

Ceiling rationale. The ceiling makes three claims: relational trust strong enough for mutual accountability; a clear framework for what each organisation will do differently; and an outward-facing, influential board. The bridging sentence to domain 5 was added at the second revision to ensure that strong statutory partnership scores do not obscure absent community engagement. The PCH/ADASS distinction between individual accountability, organisational accountability, and collective board accountability is the direct reference for the accountability framework.

Domain 5: descriptor rationale

Floor rationale. The first draft's floor opened with "the board has no VCFSE representation among its members." This was revised to "limited or no representation beyond Healthwatch" because it is a more typical and recognisable starting position. Most boards have Healthwatch representation; the real gap is the absence of broader VCFSE voice and the absence of systematic community intelligence. The floor's second paragraph, on competitive tendering and its effects on VCFSE capacity, is directly evidenced by the peer review material and by PCH collaborative community approach model, which identifies competitive tendering as actively undermining the collaboration on which place-based working depends.
Score 3 note rationale. The note was revised to be more specific about the two conditions a growing board needs to demonstrate: VCFSE representation and at least one example of a priority that shifted in response to community intelligence. The qualifier about commissioning culture not having changed is important: a board that has representation but has not changed how it commissions is at score 3, not score 4 or 5.

Ceiling rationale. The ceiling's opening claim, that communities are "active participants in shaping the board's priorities, not consultees," is the most direct statement of the Scottish Approach to Service Design's "designing with, not for" principle applied to HWB governance. 

Domain 6: descriptor rationale

Floor rationale. The floor describes a board that treats neighbourhood health as an NHS programme: receiving presentations, endorsing plans, and playing no active part in the vision or the planning. The second paragraph makes the specific claim that the national NHS goals are being treated as the ceiling of neighbourhood health ambition rather than as minimum requirements. This is the substantive risk that motivates the domain: a board that is compliant with NHS neighbourhood health requirements but has not established its own population health and wellbeing and place-based vision. The "reflections on neighbourhoods" PCH note directly evidences this pattern.

Score 3 note rationale. The note describes a board that is pressing the ICB to go beyond the national metrics but whose contribution remains primarily challenge and oversight rather than co-leadership. This is a meaningful intermediate state: the board is engaged but not yet leading. The reference to neighbourhood geographies is specific and observable: a board that has had an active conversation about what boundaries make sense for its communities is ahead of a board that has accepted NHS administrative boundaries without discussion.

Ceiling rationale. The evidence base is the most extensive of any domain, drawing on Calderdale, the neighbourhood health framework, PCH collaborative community approach model (including the Torbay statistic), and PCH's own reflections note. This reflects the fact that domain 6 is the newest and most complex domain in the matrix, with the least established evidence base for ceiling-level practice.

Domain 7: descriptor rationale

Floor rationale. The floor describes a governance architecture shaped by council committee conventions rather than by the requirements of a strategic partnership. The PCH governance slide's diagnostic questions are the direct reference: excessive papers, items seen elsewhere, agendas focused on reporting rather than deciding. Officer support is described as primarily clerking, drawing on PCH's own observation that boards often benefit from support that goes beyond clerking to active strategic development. The floor's closing sentence, noting that the board has not reviewed whether its arrangements are fit for purpose, is the most actionable diagnostic indicator: a board that has not had this conversation is at score 1 regardless of how long it has been in operation.

Score 3 note rationale. The note describes a board that has reviewed its ways of working and made concrete changes, but where the committee culture persists in how papers are written and presented. This is a common and recognisable transitional state: the meeting structure has improved but the underlying culture of governance as compliance rather than strategy has not fully shifted.

Ceiling rationale. The ceiling was revised to add population health and wellbeing improvement as an explicit purpose reference in both the primary question and the ceiling descriptor. The public meetings language was revised from an implication that public meetings constrain effectiveness to a framing of public accountability as a design challenge: "the board has considered how to create appropriate space for candid strategic conversation while fully meeting its public accountability obligations." The ceiling's treatment of membership (actively reviewed against strategic priorities, statutory membership as the floor not the ceiling) reflects PCH's governance principle that "form follows function": governance arrangements should be shaped by what the board is trying to achieve.