Are health and wellbeing boards part of the solution?

Aficionados of The West Wing may recall the President's chief of staff, Leo McGarry remark that there are two things you never want to see made - laws and sausages. Vegetarian observers of the passage of the Health and Social Care Bill might agree on both counts. But amidst the hullabaloo about price competition, any willing provider and the replacement of primary care trusts and strategic health authorities with GP commissioning, one aspect of the Bill that has attracted remarkably little controversy is the proposal for health and wellbeing boards (HWBs).

On the contrary, the mood music here is positively upbeat. The world of local government heralds this proposal as a new renaissance in its relationship with the NHS. A total of 134 out of 152 top-tier councils have volunteered to become ‘early implementers' of HWBs – an impressive tally bearing in mind the constitutional independence of local government from central government or NHS control. From the work we’ve been doing to help local authorities and their health partners set up these new arrangements, it's clear that some GP leaders see the advantages of working more closely with their local councils. And there are signs that large powerful acute trusts see a potential role for HWBs in offering system coherence – leadership even – that appears conspicuous by its absence from the rest of the new architecture. In contrast with the high-octane controversy about the rest of the reforms, their pace and timing, a strong consensus is emerging that a ‘pause’ in this part of the reforms would be a backward step and that the implementation of HWBs should continue apace.

So why the positive glow around HWBs? Advocates claim they address longstanding concerns about the democratic legitimacy of the NHS by clarifying and strengthening its relationship with local authorities. And with most places having shadow boards in place this year, they offer a fixed organisational point in the otherwise turning world of change within the NHS, providing a platform on which local system leadership can grow. HWBs bring together a range of other public service interdependencies – including public health, housing and children's services – that could otherwise become scattered and fragmented, and they can inject new vigour into attempts to create more integrated working across health and social care. Such integration is acquiring new urgency in response to the rising tide of long-term conditions, dementia and frailty, as we signalled in our paper earlier this year.

However, real concerns remain. First, HWBs will quickly exhaust their credibility if local authority leaders fail to step up to the plate and support their NHS partners in tackling tough service reconfiguration decisions that are crucial to the financial challenges ahead. There can be no better example of the premium placed on mature political leadership by localism. Second, while local authorities have years of experience of commissioning social care services to share with fledgling GP commissioners, they should not underestimate the complexities of commissioning some kinds of health care and the specialist capacity required to do this well. There is a separate argument about local government’s role in health commissioning that should not be confused with the essentially strategic role of HWBs. Finally, those old enough to remember Joint Consultative Committees (set up in the 1970s to promote joint working) will need no reminders about the dangers of re-creating talking shops. HWBs need to be crucibles of change and to achieve the kind of co-ordination and joining-up of local services expected of them (something that has never been consistently achieved by any set of reforms since 1948); they will require stronger powers than those contained in the current Bill. Amendments in this area could deal with some of the concerns about accountability of GP consortia for the use of public funds, for example by strengthening HWB oversight of consortia commissioning plans, thus offering an immediate stepping stone to help get the government's reforms on a more stable and promising trajectory.

Whatever the outcome of the 'pause', HWBs do seem to be part of the solution, not the problem, and – back to Leo McGarry’s sausages – might yet help save the government's bacon?

We'll be exploring these issues further in our summit on health and wellbeing boards

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#428 John Wilderspin
National Director, Health and Wellbeing Board Implementation
Department of Health

Richard; very thoughtful contribution to the debate about how Health and Wellbeing Boards can add real value.

My sense from talking to a wide range of people involved in setting up Boards is that there is a strong desire for them to make a positive difference, and not just be "talking shops". There is also a recognition that all the leaders sat around the Board, NHS and local government, will need to be courageous and take some difficult decisions if they are to make real change happen. The challenge is how to do that in a world of realpolitik, financial pressures and organisational change, and that is what is exercising people's minds at present.

Local authorities and their NHS partners are very keen to find the solutions to these challenges by working together at a local level, and by sharing learning more widely. In collaboration with partners, including the Kings Fund, we are developing the process by which they can do that in a way which enables them to "co-produce" the solutions for themselves. Your Health and Wellbeing Board summit on 14th July is an example of how we can do that, and I'm look forward to joining you at that event.

#429 Nick Pahl
British Acupuncture Council

I hope I can provide a practical example of how health and wellbeing boards may be able to improve local people's health.

I have worked in the NHS in public health and commissioning roles and am currently CEO of The British Acupuncture Council (BAcC) - which represents over 3,000 professional acupuncturists.

I would hope that health and wellbeing boards will facilitate
- joined up health and social care
- analysis of need - e.g. people may want support for therapies such as acupuncture to improve their health
- facilitate further use of personal budgets for people with health and social care neeeds

We recommend that the early health and social care boards engages with local practitioners in and out of the NHS in order to evaluate the "care community" that exists locally.

#430 Brendan Young
Independent Public Health Campaigner
Independent Worcestershire People

I applaud the enthusiastic uptake of the HWBs by local authorities to enable them to fully engage with the NHS through GP Commissioning Consortia and NHs Trusts.
I'm somewhat confused about the leadership of these organisations and the level of patient/public involvement and accountability.
In my locality we currently have a Health Scrutingy Committee comprising publicly elected Councillors who have failed to demonstrate any significant understanding of Health Policy and Decision Making within the LHE.
I can't see how the principle/slogan of "No decisions about me, without me" will be relevent to local accountability when I suspect that the re-cycled PCT senior managers (now Consortia employees) will continue to bamboozle the local authorities with quick fixes that may not produce satisfactory patient care.

#432 Jon
Service Development Manager
New Zealand

Interestingly, the HWBs seem to be analogous to the District Health Boards in New Zealand. These groups are elected bodies, with additional statutory appointments for balance. The predominant issue we face is understanding within these groups of the determinants of health, and the strategic issues faced with reducing morbidity and mortality.
It would seem from my experience that despite a population focus most spend their time worrying more about the hospital than Primary Care or population health. it will be interesting whether this is the case in the HWBs.

#436 Tess
Polycystic Kidney Disease Charity

Richard, I found your posting alarming and confusing.

You wrote of "fledging GP commissioners" (very scary), and a "separate argument about local government’s role in health commissioning" (what is that) and "the essentially strategic role of HWBs" (who has defined that strategy?) and "strengthening HWB oversight of consortia commissioning plans" (I thought the NHSCB did that).

What happens when we have a draft Public Health Bill to think about too? It all sounds like political mayhem to me with no patient benefit.

#437 Andrew Craig
The Moore Adamson Craig Partnership LLP

What do we need HWBBs for? We should be working for integrated commissioning across all levels of health and care and between sectors. That implies a single commissioning structure, not one that is split between NHS and Town Halls. Of course let's have more democratic legitimacy, but having a few councillors sitting around talking with the director of public health isn't going to achieve that. Independent scrutiny of health and social care, strong Local Health Watch, independent lay members as well as patient representatives at all levels of decision making, stronger Foundation Trust members and elected governors to hold boards to account - these are the makings of the system we need together with involvement of local councillors. HWBBs should be jettisoned after the Future Forum reports, otherwise we just add to the bureaucracy for no gain to patients and carers and the public. The Bill must be changed to achieve integrated commissioning. This means more than just consortia being clinically led.

#440 Richard Humphries

Tess - thanks for your post, sorry if I've alarmed or confused you! To clarify, there has been a longstanding view by some that health commissioning should be transferred to local government and I wanted to make point that this is not role of HWBs - their strategic role is to ensure good understandling of local needs (through JSNA) and produce an overall framework (health and wellbeing strategy) within which consortia & NCB commission services. You are right that the latter is responsible for overseeing outcomes of consortia commissioning plans, but HWBs have overall responsibility for promoting integration and taking overall view of needs and outcomes. Not sure current Bill gives them enough powers to do this properly. Hope this clarifies.

#441 Richard Humphries

Andrew - I agree we should be working towards integrated commissioning and in the current Bill the HWBs are the only part of the new arrangements charged with doing that. To have a single commissioning structure you describe would require change on a scale even more radical than the current bill and probably a complete unpicking of local government finance. I do not see this happening any time soon. Whatever happens with the Bill, there will always be a need for some kind of local mechanism that brings together commissioners and providers across NHS, local govt and third sectors, and acute health care, public health, children's services, adult social care and local govt.

#488 G Huisman

I really, really struggle to work out how to marry up the inherently very localised focus of future Clinical Commisioning Groups, with the inevitably regional (County Council in our situation) focus of these HWBs. Will local groups of clinicians really appreciate the interference of yet again another distant (culturally and geographically) public body.

The biggest draw of the reforms (for me) was the abolishment of large, remote PCTs and their replacement with smaller and locally much more relevant CCGs (or whatever name they are going to get...) and the prospect of having to deal with another armslength potentially interfering organisation is in first instance not very attractive...

The suggestion that nothing useful on these lines has ever been achieved since 1948 makes one wonder whether the optimism displayed isn't ever so slightly misplaced

#528 Mr Christopher ...
Managing Director

To be effective it must involve patients and carers.

#541 Elizabeth Bayliss
Social Action for Health

The perennial question is, how can we achieve joined up working between health and social care providers that is firmly based on the needs of local people? The proper tension between commissioning and providing local service provision and recognising local needs is simply not addressed in the proposed new bill - as usual, a simple focus is being sought that is really just about service integration, across the public sector, instead of seeking to hold a proper 3 way balance between commissioning, service provision, and local needs. Triangulation is a much strong base and creates the space for local innovation.

Elizabeth Bayliss

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