Although many of the provisions in the Health and Social Care Bill 2010-12 were the subject of great controversy as the Bill made its way onto the statute book, the proposals for the creation of health and wellbeing boards (HWBs) have been universally welcomed by local government (demonstrated by the fact that 90% of affected local authorities signed up to pilot HWBs ahead of the April 2012 statutory deadline). Although the purpose of HWBs is to encourage local authorities to take a more strategic approach to providing integrated health and local government services by bringing together those involved across the NHS, public health, adult social care and children’s services, concerns have been raised as to how effective the boards will be, see Article, Health and wellbeing boards and public health.
In view of these concerns, the report, “Health and wellbeing boards: system leaders or talking shops?”, published by the health thinktank, The King’s Fund, makes interesting reading. It is based on a survey of how 50 local authorities are implementing the new HWBs. In addition to the survey’s findings, the report presents case studies from two early implementers. The purpose of the King’s Fund research was to:
- Gain an insight into how local authorities and their health partners have gone about implementing HWBs in the context of the government’s NHS reforms, its vision for adult social care and the Localism Act 2011.
- Capture the overall approach of a sample of English councils in establishing these new arrangements, together with a more detailed examination of the experience of two early implementer sites (Lambeth and Surrey).
- Identify the lessons that could be applied to the roll-out of HWBs, the issues that local authorities and their health authorities need to address and the implications for policy.
The report refers to the 1974 NHS reorganisation on the basis that much of the historical evidence and experience from that time of joint working and co-operation between health and local authorities offers some interesting precedents for HWBs. The 1974 NHS reorganisation placed a new duty on health and local authorities to establish joint consultative committees (JCC) to facilitate co-operation and joint planning. It is widely thought that JCCs did not have sufficient decision-making powers as they started life as advisory and not executive decision-making bodies in much the same way as HWBs have been criticised for not having sufficient decision-making powers. Although efforts were made in 1974 to strengthen JCCs by the addition of joint care planning teams and joint finance, the changes had a limited effect because of the small amounts of money involved and the difficult economic circumstances that prevailed in the 1970s which necessitated large-scale public spending cuts.
Even though today’s arrangements for HWBs differ from those in 1974, the King’s Fund report considers that HWBs will face many of the same challenges faced by the 1974 JCCs. In addition, HWBs will have to adopt a strategic approach to promoting integration and achieving better outcomes for their local population by influencing and leading across organisational and professional boundaries in the context of a complex organisational NHS structure, in which the roles of clinical commissioning groups, the NHS Commissioning Board and local authorities still remain unclear. This task will be undertaken by HWBs in the face of even greater financial pressures than those that undermined the JCCs in 1974.
What is apparent from the report is that more than 80% of the surveyed authorities already had some form of strategic health and care partnership board in place meaning that they were able to move quickly to establish HWBs. Other issues highlighted in the report in relation to HBWs include:
- Depending on the type of authority, limiting board membership to below 20 members. Shire counties are singled out as experiencing greater organisational complexity as they find ways of engaging with several clinical commissioning groups as well as second tier of district councils. In particular, the report refers to Surrey County Council working with more than 20 statutory bodies, including 11 district councils and 12 nascent clinical commissioning groups.
- How the new boards are to be resourced and serviced. Although local authorities are expected to establish HWBs, additional resources to do so are not available. The report comments that some respondents to the survey have been using council democratic teams as administrative capacity for the HWB while others have been using existing project management capacity. This relates only to how they function.
- Whether the effectiveness of HWBs will be hindered by budget constraints leaving them with insufficient resources to tackle health inequalities and the wider causes of ill health.
- The respondents’ views that, compared with previous joint working arrangements, HWBs have the benefit of:
- greater involvement and/or engagement of GPs;
- better governance and accountability because of their status as a committee of the local authority;
- greater ability to set the strategic direction for health and wellbeing in the areas;
- greater partnership working between organisations;
- greater influence because their creation is a statutory requirement; and
- a strategic focus on commissioning.
- Whether the locally agreed health and wellbeing strategy that HWBs have to produce will influence local commissioning decisions. Most of the respondents to the survey considered that their strategy would be influential in relation to the decisions of clinical commissioning groups but not in relation to those of the NHS Commissioning Board. The report points out that this mirrors expressed concerns about the relationship between HWBsand the NHS Commissioning Board, particularly given that the NHS Commissioning Board will be responsible for commissioning all local primary care, dentistry and pharmacy services (as well as specialised services) and will have £20 billion of the total NHS budget to do so. If HWBs are to promote the strategic co-ordination of all local services that are relevant to health and wellbeing, they will need to influence all commissioning activity affecting their local population, including the NHS Commissioning Board.
- How HWBs will assess their impact and success. The report highlights that some local authorities plan to measure the performance of their HWBs against the delivery of stated objectives in work programmes, joint strategic needs assessments and the joint health and wellbeing strategy while others see their oversight and scrutiny committees as having a role in regularly reviewing the actions and performance of the HWB.
What the report does show is that most local authorities are still in the process of developing their way of working and trying to set up HWBs that are not too large or unwieldy and will be fit for purpose. Undoubtedly, achieving the right balance will be harder where there are two tiers of local government and multiple clinical commissioning groups or where the bodies of the clinical commissioning groups and local authorities are co-terminous. However, given that the primary purpose of HWBs is to promote integrated care, this should be their major policy priority. HWBs must not be seen simply as an additional layer of meetings that add costs rather than value to local partnership arrangements.
The good thing is that the shadow year offers local authorities the time to develop a strong framework for integrated care.