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?