Seven years on, there have been fundamental and far-reaching changes in how the NHS works across different services and with external partners such as local government. There is a new emphasis on collaboration, population health and integration, including new models of care and sustainability and transformation partnerships (STPs), which are evolving into integrated care systems (ICSs). The NHS long term plan recognises the importance of local government’s engagement in these developments but evidence from our work suggests that in many places this has been patchy.
What do these developments mean for the future role of HWBs? This long read examines the part HWBs, and local government more broadly, have played in the emergence of ICSs so far and options for their future. We have drawn on our work on STPs and ICSs, as well as other national research and evidence. We have complemented this by talking to ICS and local government leaders in five places where there has been a positive track record of local authority engagement.
This long read explores questions in three main areas:
- What has been the overall role and contribution of local government to ICSs so far? How involved have councils been? How far has this influenced the development of ICSs and how they work? How helpful or otherwise has this contribution been?
- To what extent does the HWB feature in the overall governance arrangements for ICSs, both now and in the future? How does this work in practice, for example, where there is more than one HWB in the ICS footprint?
- What part has the HWB played in the development of ICSs so far and how far might this change in the future, taking account of proposed national changes in NHS legislation? What is the future of HWBs in a world of ICSs?
HWBs, STPs and ICSs – a brief history
HWBs came into being on 1 April 2013, in all 152 local authorities with adult social care and public health responsibilities, after operating for a year in ‘shadow’ form.
HWBs are a formal committee of the local authority and were originally seen as the primary engine room for local integration and partnerships across the NHS, public health and local government. They have a statutory duty, with clinical commissioning groups (CCGs), to produce a joint strategic needs assessment and a joint health and wellbeing strategy for their local population. The boards have very limited formal powers. They are constituted as a partnership forum rather than an executive decision-making body.
In December 2015, NHS planning guidance announced the introduction of sustainability and transformation plans. These brought together local NHS organisations and local authorities to develop long-term plans for the future of health and care services in their area. Forty-four areas of England were identified as the geographical ‘footprints’ for the STPs. Over time, the emphasis has shifted towards developing and strengthening local place-based partnerships – sustainability and transformation partnerships (STPs). These are now evolving into ICSs, a closer form of collaboration in which the NHS and local authorities take on greater responsibility for managing resources and performance. The NHS long term plan announced that ICSs will cover the whole country by April 2021, thus replacing STPs.
Local government’s role – the story so far
Planning guidance for sustainability and transformation plans, published in 2015, recognised that their success would depend on active engagement with partners, including ‘local government through health and wellbeing boards’ – although this was the only reference to HWBs in the guidance.
The involvement of local authorities has varied widely between STP areas, ranging from strong partnerships between the NHS and local government to almost no local government involvement. A 2017 Local Government Association survey of elected councillors in 68 councils found that, overall, most perceived there to be low engagement in the STP, with 69 per cent stating that councillors were not sufficiently engaged in their local STP and 71 per cent believing that councillors were not sufficiently involved in the governance of the local STP. However, they perceived the engagement of HWBs, and of local authority senior officers, to be much higher.
There is little evidence that HWBs in most places have had much influence on the development of STPs. There have been concerns that STPs have subsumed much of the work of HWBs but over a larger geographical area, so undermining the value of local place-based collaboration. Participants in a national evaluation of HWBs viewed STPs as ‘potentially eclipsing HWBs’ and that, with the advent of ICSs, ‘the eclipse risks becoming total’.
Our initial assessment of eight of the ten of the first wave of ICSs in 2018 showed that local authority involvement remained variable but in most cases local authorities were part of the ICS board and/or other parts of the governance structure. The Care Quality Commission carried out a review of 20 local health and care systems in 2017 and 2018 and concluded that HWBs vary in their effectiveness as forums for exercising wider oversight of the system and for promoting transformational change. It found that HWBs and STPs took different roles in different places, depending on their maturity and effectiveness, and that ‘differing geographies and leadership behaviours could create a disconnect between an STP, HWBs and the local systems we reviewed’.
The National Audit Office has noted that while there is evidence that the effectiveness of HWBs is improving, some concerns remain, citing the Local Government Association’s view that ‘partnerships are, in general, getting better at involving local authority partners and at incorporating health and wellbeing boards into their governance arrangements'. In What a difference a place makes: the growing impact of health and wellbeing boards, the Local Government Association highlights the achievements of 22 HWBs, including their contribution to STPs and ICSs, while noting that the maturity and impact of all HWBs around the country varies. Not all are as effective as they could be, and some need to do more to reach their full potential.
The power of place
Many of the leaders we spoke to, from both the NHS and local government, highlighted the distinctive contribution of local government in recognising the power of place in ICS development and the value of:
- collaborating at different levels in the system
- building up from places and neighbourhoods
- providing leadership across the system
- focusing on functions that are best performed at scale.
This corresponds to the three broad levels of activity identified in our previous assessment, with some differences in the terminology used.
The West Yorkshire and Harrogate Health and Care Partnership, for example, has agreed a memorandum of understanding, with subsidiarity as a fundamental working principle. The primary units of joint working are six place-based partnerships across the ICS area, overseen by HWBs whose role is to:
- develop a shared understanding of local needs
- provide system leadership to meet those needs
- influence commissioning decisions
- involve councillors and patient representatives in commissioning decisions.
Below this level, GPs along with community health and social care services deliver integrated care across 50 to 60 neighbourhoods to smaller populations of 30,000 to 50,000 people.
Three tests are used to determine when to work at the ICS level:
- to achieve a critical mass beyond the local population level to achieve the best outcomes
- to share best practice and reduce variation
- to achieve better outcomes for people overall by tackling ‘wicked issues’ (that is, complex, intractable problems).
The Suffolk and North East Essex ICS has constructed its governance on the foundation of three ‘place-based alliances’, each defined by the footprint of local health and care partners as well as natural geography, developing differently according to local circumstances. Each alliance involves multiple partnerships, including NHS organisations and local government, as well as PCNs, working together to deliver integrated care and improve population health across organisational boundaries. There is active representation from district councils and voluntary and community sector partners. The ICS will take on roles and functions only where there is an ‘identified requirement’.
Local government has helped
National evidence points to very variable patterns of engagement between local government and the NHS, not only between ICSs in different parts of the country but also between local authorities within the same ICS system, reflecting different working relationships, personalities, changes in the organisational landscape, and history of financial and performance challenges.
But predictions that ICSs will totally eclipse HWBs may be premature. A pattern is emerging of local government playing a stronger role in the emerging ICSs than it did in the early days of STPs. NHS leaders we spoke to were very positive about working with local government colleagues, and several felt that their ICS had developed in a different and better way as a result of local authority involvement. This is perhaps not surprising given that they are from areas with an established track record of working together but it illustrates the progress that can be made and the benefits to the NHS of investing in building relationships with local government colleagues. Examples included drawing on local authorities’ greater experience of public engagement and the benefits of spending time with elected members discussing controversial issues such as hospital reconfiguration proposals. Although difficult, these discussions had enabled a deeper understanding of how local government works and the role of elected members. In two places, the HWB had approved the governance framework and it was felt that this had added a degree of democratic legitimacy to the ICS.
Leaders in three of the five systems we studied described how the influence of the local authority had led to a different style of working that had significantly softened the traditional top-down, nationally driven approach of the NHS and placed stronger emphasis on finding local solutions to locally agreed needs and priorities.
As well as promoting the importance of place, local government leaders we spoke to felt that The NHS long term plan had created a stronger sense of shared purpose, because many aspects of the plan – such as prevention, improving population health and tackling health inequalities – are central to what local authorities are trying to achieve, including the contribution of economic development strategies to local health and wellbeing.
Leadership is everything
A key factor that drives the effective engagement of local government in ICSs is the nature and quality of local leadership – within NHS organisations and local authorities and across the whole system. Invariably this involves a style of leadership that is open, inclusive and engaging, seeking a better understanding of each other’s challenges, recognising – and respecting – fundamental differences in governance, accountabilities, funding and performance regimes and seeking ways of managing these differences.
Leaders in the five systems we studied all described a history of good working relationships, with stability and continuity of people in key positions. This is a thread that runs continuously through much of the evidence about collaborative working, partnerships and integration. Suffolk had a well-established tradition of working together, through a longstanding public sector leaders’ group bringing together all of the local authorities, NHS organisations and the Police in Suffolk to discuss strategic issues affecting the whole county.
Leadership by local authority elected members is also important. In West Yorkshire and Harrogate, the eight local authorities, their leaders and HWB chairs had worked together to ensure there was a single, strong local government voice in their ICS – in addition to preserving a place-based approach for the people in their own local authority areas. This led directly to the creation of a partnership board as part of the overall ICS governance (discussed later).
Effective political leadership has also enabled the separate HWBs of Warwickshire and Coventry councils, despite differences in party political control, to agree a concordat setting out how they will work together to improve the health and wellbeing of their population. This should enable them to contribute much more effectively to the STP covering both their areas and directly influence its evolution into an ICS.
These examples illustrate how good leadership has enabled people to focus on outcomes and relationships and escape a narrow view of HWBs as council committees. Interestingly, interviewees were generally much more enthused about the value of good relationships with each other than the structures, such as HWBs, through which they are expressed. This is a reminder that governance and organisational arrangements are only as good as the quality of relationships between people and organisations.
Governance is complex – ‘work in progress’
The organisational landscape in many ICSs is complex, especially in areas where there is more than one HWB and many local authorities span multiple STPs. The West Yorkshire and Harrogate Partnership, for example, comprises twenty-two NHS bodies, eight local authorities and eight other local partners. In county council areas there is the complication of a second tier of district councils whose engagement is important because of their important functions around housing, leisure and other services. Natural geography, administrative boundaries and patient flows rarely coincide.
Local NHS leaders are trying to design and develop their ICS, and the new style of working it involves, within existing structures and arrangements that the Health and Social Care Act 2012 established for very different purposes. They are doing so with the benefit of significant local discretion in the absence of detailed and prescriptive guidance (although there seemed little appetite among our interviewees for such guidance). There is no national governance framework for ICSs and they have no formal executive powers, relying on the voluntary agreement of the NHS bodies involved.
This means governance arrangements are inevitably in a state of flux and are being developed by each ICS. Progress at this relatively early stage can be described as ‘work in progress’. Several interviewers raised the questions: What is the purpose of the ICS board? What is it there to do? It is unsurprising that the interface with local government generally, and HWBs in particular, is still under development when the primary purpose of ICSs is still under discussion.
The national evidence and our interviews suggest that like the STPs that preceded them, there are different degrees of pace but signs that the new ICSs are making progress in finding common cause with local authorities and some are beginning to develop formal governance arrangements that reflect this.
In Dorset, local government reorganisation has streamlined a two-tier system of nine councils into two unitary authorities and has spurred fresh thinking about working with the NHS. The new Bournemouth, Poole and Christchurch HWB has been clear from the outset that contributing to the governance of the ICS is part of its role and this will involve measuring progress against the plans of the ICS and the joint health and wellbeing strategy. In Frimley, a single health and wellbeing alliance board has been created to feed into the governance structure; in Buckinghamshire, the ICS partnership board reports to the HWB as the statutory body responsible for setting the system’s joint health and wellbeing strategy; and in Bedfordshire, Luton and Milton Keynes, the four councils have established a joint scrutiny committee. A common theme in these emerging arrangements is that many HWBs see their ICS as being accountable to them for the delivery of health and wellbeing outcomes for their local population, although as yet this does not appear to be reflected in the formal governance arrangements of the ICS.
Essex and Suffolk County Councils have held a joint ‘assurance’ meeting, involving the chairs of both Councils’ HWB and the council’s oversight and scrutiny committees and NHS England, to review and assess the first five-year plan of the Suffolk and North East Essex ICS.
HWBs covering the same ICS area are working together in different ways to mitigate organisational complexity. In Coventry and Warwickshire, the two separate HWBs operate as a joint board, or as a ‘place forum’, supporting the work of four local place-based partnerships. In West Yorkshire and Harrogate, HWB chairs are members of an ICS-wide partnership board alongside their council leaders and the chairs and chief executives of NHS organisations – an interesting model for bringing together elected members with NHS non-executive directors. Other places use more informal ways of HWBs working together, such as periodic informal meetings of HWB chairs or joint annual board meetings.
The future – brave new world or remembrance of things past?
The legacy of local authorities’ minimal involvement in STPs does appear to be fading, with evidence of much stronger engagement in the emerging ICSs. The commitment of The NHS long term plan to forge strong links between the NHS and its communities, citizens and local government has helped this. Local government has welcomed the plan’s emphasis on prevention, public health and population health. This seems to have generated fresh energy and impetus for working together.
Turning to HWBs, their future prospects are less clear. Created in 2012 as part of a policy compromise between the two political parties in the coalition government (the Conservatives and the Liberal Democrats), they are operating now in a fundamentally different national policy regime based on collaboration, system leadership and closer integration between different parts of the NHS as well as local government. Given that the main purpose of HWBs was always to promote integration at the local level, arguably they are more relevant than ever, possibly even as an idea whose time has now come. But at least two overall scenarios seem possible.
In many places, especially those without strong leadership, a history of poor working relationships and little engagement with the NHS, their functions might become subsumed within ICSs, as the national evaluation of HWBs warned. In other places, where there is continuing local support, they might continue to meet but become increasingly marginalised, and ignored, having minimal impact on ICSs, which are seen as the ‘go to’ place for all important decisions.
In July 2019, Matt Hancock, Secretary of State for Health and Social Care, described a different scenario: he called for HWBs to be ‘empowered’ as ‘the vital component in bringing together local authorities, NHS commissioners and elected representatives to create a strategic vision for a local area so we’re accurately identifying needs, and co-ordinating care’. He challenged local government leaders by asking: ‘How strong is yours? What can you do to strengthen it?’. An example of an ‘empowered’ HWB might be one that holds its local ICS to account, as discussed earlier.
NHS England and NHS Improvement has put forward proposals for legislative change to remove barriers to collaboration, in which it also describes a continuing role for HWBs. It envisages that HWBs will continue to play an important role in assessing local needs and developing joint health and wellbeing strategies, to which ICSs should ‘pay close regard’. The proposals make it clear that ICSs are expected to work closely with the HWBs in their localities.
But the proposals also involve giving local NHS bodies and ICSs the power to create new joint committees of CCGs and NHS providers to make legally binding decisions that are not possible under current legislation. Where necessary, local authorities and other partners could be invited to join these committees. There is a risk of creating an alternative, NHS-based parallel structure – thus contributing to the increasing marginalisation of HWBs – unless the respective roles of these new joint committees and HWBs are clear.
The experience of STPs and ICSs so far demonstrates the importance of place as a vital footprint for the planning and delivery of services, using the principle of subsidiarity to determine which functions should be performed across the wider area of the ICS. Decades of different integration initiatives have showed the need for some kind of local partnership vehicle to bring together organisations at the local authority level. Our previous work on HWBs concluded that if they did not exist, something like them would need to be invented.
While the value of strong relationships between the NHS and local government commands more support than ever, views about the role of HWBs as the vehicle for those relationships are mixed. In the early days of STPs, many in local government perceived them to be just about the NHS and this is mirrored in NHS leaders’ continuing perception that HWBs, as statutory committees of local authorities, are only about local government functions.
Even the most ardent champions of local government engagement, and their NHS partners, describe the continuing effort needed to manage the profound differences between the modus operandi and culture of the ‘national’ health service – as a centrally managed and accountable service – and that of ‘local’ government. There are concerns that the NHS ‘juggernaut’, as one interviewee put it, can easily default to the latest national edict and distract NHS colleagues from sticking with locally agreed plans. There is a particular fear that if CCG mergers ‘typically’ result in one CCG per ICS, as The NHS long term plan suggests, this could undermine the progress that CCGs and local authorities have made at that important level of place.
This suggests that there are three areas that need attention if local government and HWBs are to make a full and effective contribution to the ICSs that are expected to be in place in all parts of the country by April 2021.
- The promised statutory guidance on ICS joint committees should reinforce the positive role of local government, citing examples of where local government is already engaging and the benefits of this engagement. It should make it easier, not harder, for local partners to find local solutions and not undermine the progress that some ICSs have made. Its authors should heed the words of the late President Reagan that the nine most dangerous words in the English language are: ‘I’m from the government and I’m here to help.’
- The current role and functions of HWBs should be reviewed and refreshed, and consideration should be given to whether any changes would improve their effectiveness, for example, by strengthening NHS membership and giving boards more powers over budgets and decision-making, subject to local agreement. The Department of Health and Social Care should also ensure that any revised guidance is consistent with the guidance on ICS joint committees to be issued by NHS England and NHS Improvement. The guidance should ensure that there is national clarity about the purpose and functions of ICSs, and assert the positive benefits of local government engagement and the value of place-based partnerships such as HWBs within ICSs, without compromising the scope for local arrangements that have driven much of the progress so far.
- Local authorities can learn from the experience of their colleagues in the first wave of ICSs by making sure they are working together effectively to offer a strong local government contribution to the ICS in their area, based on a clear vision for the health and wellbeing outcomes for their local population.
I agree with Matt Hancock's remark that HWBs should play a much bigger role than they currently do. I am in correspondence with Earl Howe and Lord Lansley about why the HSCA 2012 has not worked, and how it can. Please engage with me to send you copies of the draft paper. In summary the provisions of the Act have been subverted by the drug companies, who have spread fake news, but I show how it could be made to work by getting HWBs to work with CCGs in the traditional member/officer relationship, which could transform mental health and solve the crisis in primary care. You can ring me on 01273 417997, and look at www.caspott.org.uk.
Thanks John. You can send your paper to me via the email link here https://www.kingsfund.org.uk/about-us/whos-who/richard-humphries
Hi Richard, a very interesting assessment. Do you have any reflections on improvement in safety and quality though the more effective cross organisational collaboration at local system level (primary, secondary, social and community care); whether the opportunity for improvement and redesign is recognised, planned and being delivered?
We reflect on safe system thinking in our Blueprint for Action (https://www.patientsafetylearning.org/resources/blueprint). It would be great to be able to share examples of good practice that are emerging on our new knowledge sharing platform for patient safety, the hub (https://www.pslhub.org/)
Small point, RIchard, and a larger one. Nomenclature changes rapidly. BOB is now the ICS while the Bucks arrangement (which you note as reporting to the HWB) is surely classified as an ICP.
But the bigger point is about political identity. Your appraisal of HWBs makes mention of party but only briefly. But the political colour of a local authority matters, a) in fiscal terms, b) in terms of the alignment of councillors and council policy with ministers. The ideological basis of the Conservative and Labour parties has been shifting, at Westminster; recent polling stamps a particular colouring on the views of party members. That suggests that councils' political colouring will be changing too - rightwards and leftwards respectively. Unless, somehow, the selection of councillors is immune from wider intra-party movements, which seems unlikely.
So there's basic asymmetry in relations between councils, party dominated, and NHS bodies, which eschew partisan identification.
Some people try to argue that local government business is mainly 'technocratic' and unpolitical. Others say there's fundamental agreement. That's debatable but if it were so, local democracy becomes problematical because 'choice' is evacuated.
But the more distinct local political choices are, the more difficult surely the marriage of NHS purposes and local government policies.
Is this another nibble at the who pays for the bath problem? I remember NHS Leeds writing that housing is the key to health and community care, earlier Alma Ata defined clearly what health for all means.
Two things seem to be being lost currently -,that children’s services have solved many of these issues, and if we are serious about being person centred health and local government must cooperate - the health juggernaut is very real