In the context of the changes set out in the recent NHS long term plan (2019), Dr Anna Coleman draws our attention to the recently published LGA report which highlights some of the good work that Health and Wellbeing Boards have been undertaking since they were introduced in 2013. She suggests the new place-based system of working (Integrated Care Systems) could usefully learn from them how to operate successfully across sectors and organisational boundaries, include an element of democratic accountability and create strategic partnerships of equals.
- The early development of Health and Wellbeing Boards showed potential for local integration, but some cases were hampered by a lack of local willpower or statutory basis.
- As strategic thinking in health moves towards Integrated Care Systems (successors to Sustainability and Transformation Partnerships), we should remember that HWBs have been piloting similar place-based approaches to integrating health and social care since 2013.
- The experience of HWBs should be learned from and built upon as Integrated Care Systems are developed.
In response to common and enduring problems facing healthcare systems across many countries, i.e. demographic change, ageing populations and patients with more demanding complex needs, the need for the NHS, local authorities and other organisations in a local area to work closely together has never been more pressing. With the realisation that no one organisation can solve the ‘wicked problems’ of society and constrained by austerity, partnership working or integration as we now term it, is all important.
Health and Wellbeing Boards (HWBs) were introduced in England following the Health and Social Care Act 2012 (HSCA12), and were shaped by statutory guidance and constituted in local authorities. They emerged as a key coordinating mechanism or steward locally for local health and social care systems.
HWBs were intended to lead the integrated assessment of local needs (JSNA) to inform both NHS health and local authority (LA) social care commissioners and oversee the production of a local joint health and wellbeing strategy (JHWS). The latter setting out a local vision, priorities and actions to be taken to improve the health and wellbeing and reduce inequalities of the populations covered. In addition, HWBs were to be responsible for encouraging integrated working between health and social care commissioners, including pooling budgets.
These statutory duties form a strong base from which strategic place-based and system-wide planning can be undertaken.
Early development of Health and Wellbeing Boards: Our research into challenges and opportunities for local integration
We conducted some early research into the newly forming HWBs and found that they varied greatly in their structure and approach, but had great potential to drive strategic working across local sectors and organisations to improve the health and wellbeing for the local population.
We also identified a number of significant issues that were familiar from earlier research into health and social care integration: heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.
Our work showed that the effective operation of HWBs in the new system was by no means a foregone conclusion. As with previous initiatives designed to increase partnership working across the health and social care divide, commitment from all partners (and individuals within these) was required to make the new system work in practice. At best, it was suggested that there is potential for HWBs to open up new and exciting partnerships, bringing in additional LA areas of responsibility, such as transport and crime prevention to work with health and social care to develop a comprehensive approach to well-being.
We found some HWBs implementing the new arrangements with enthusiasm, with a clear sense of ‘co-ownership’ of the developing local agenda. However, we also found evidence of some disconnect between some developing Clinical Commissioning Groups (CCGs) and their local HWB. We suggested that if this continued, the lack of statutory authority afforded to HWBs under the HSCA 2012 may be significant.
Two years later, the LGA and NHSCC made a plea “for a balance between national accountability and local flexibility, the removal of barriers to integration and increased place-based leadership, enabling HWBs to look at both immediate priorities for integration and action for upstream prevention”. They went on to suggest what a good HWB looked like, all of which resonate with the important characteristics of the currently developing Integrated Care Systems across England.
- Shared leadership – formed on equal partnerships between local commissioners, move away from rigid organisational cultures etc.
- A strategic approach – shared ownership, manage priorities, focus on innovation and integration and work at pace and scale etc.
- Engaging with communities – develop a vision and strategies, being jointly accountable to local people etc.
- Collaborative ways of working – openness and transparency, sharing data, risk sharing etc.
During 2016, we suggested that there was unlikely to be a single response to developing effective HWBs given the extent to which there were variations in local health and care systems and the wider context of developments following the publication of the Five Year Forward View.
Recognising the continuing relevance of Health and Wellbeing Boards for place-based approaches and leadership
The recently published LGA report ‘What a difference place makes’, states that the original objectives for HWBs are as relevant to the new NHS landscape as they were in 2013, if not more so.
The report highlights some of the work from 22 selected ‘well performing’ HWBs across England as illustrations of what can be achieved by working across local organisations to meet agreed strategic goals. The report explains that HWBs are the “only forum bringing together political, community and health leaders” and “have been instrumental in building strong relationships among equals, with trust, shared values and a common vision underpinning their shared endeavours”. It also sets out a set of challenging factors which HWBs have had to adapt to over recent years as the healthcare system has evolved. These include:
- A challenging financial context;
- Public health becoming embedded in local government;
- The increasing importance of ‘place’ across public services;
- Expanded roles of HWBs e.g. oversight of the Better Care Fund;
- Devolution, combined authorities and some new Unitary LAs;
- Increased role for District councils in health and wellbeing;
- Greater national focus on integration;
- NHS reforms e.g. planning at system (ICS), place and neighbourhood levels and a greater emphasis on system-wide partnerships.
To “remain relevant and effective” the LGA report highlights the importance of refreshing Boards, JSNAs and JHWSs which they suggest, alongside wider integration developments has led to “a renewed energy and sense of purpose”.
HWBs are also seen as more successful if their work is aligned with public health teams so tapping into ‘making every contact count’ (an approach to behaviour change), ‘health in all policies’ approaches (collaborative approach which emphasises connection between health and other policies), and the use of asset based approaches (using people’s and communities’ assets alongside their needs).
Using HWBs’ experience to inform new approaches to integrating local healthcare systems
The NHS long term plan (LTP 2019) sets out the rapid direction of travel from Sustainability Transformation Partnerships (STPs – originally established as Plans across 44 areas covering England in 2016) to Integrated Care Systems (ICSs, as set out in the LTP 2019).
The LTP states that ICSs are central to its delivery, bringing together local organisations to redesign care and improve population health, creating shared leadership and action, ultimately providing well-coordinated efficient services to those who need them. The aim is by April 2021 ICSs will cover the whole country, evolving from the previous STPs. ICSs, the plan says, will have a key role in working with LAs at ‘place’ level (250 – 500,000 population, typically LA level, so the size of existing HWBs) and, through ICSs, commissioners will make shared decisions with providers on how to use resources, design services and improve population health (other than for a limited number of decisions that commissioners will need to continue to make independently, for example in relation to procurement and contract award).
Each ICS is to have a partnership board, drawn from and representing commissioners, trusts, primary care networks, and – ‘with the clear expectation that they will wish to participate’ – local authorities, the voluntary and community sector and other partners. Despite HWBs being hosted by LAs, so potentially having the same geographical footprint as developing ICSs and already linking many of the partners vital to the success of ICSs, it is unclear how they will relate to one another. There is only a single mention of HWBs in the NHS Long term plan, where it is stated “ICSs and Health and Wellbeing Boards will work closely together” but with not clear idea how and for what purposes.
Recent (June 2019) guidance ‘Designing integrated care systems (ICSs) in England’ (.pdf) more broadly sets out the different levels of working within the developing integrated care systems, describing their core functions, the rationale behind them and how they will work together. This again makes only brief mention to HWBs stating ICSs will be expected to work closely with them, especially at the place based level. A case study, written up from a panel session (ICS leaders) at this year’s NHS Confederation conference considered the keys to achieving integrated care over the next few years. The identified factors included: the importance of relationships; getting the right systems in place, worrying less about organisational boundaries (instead know who needs to be present); sharing strategic goals, governance arrangements and risks (focus on the bigger picture); and continued work at all of the above.
A case study, written up from a panel session (ICS leaders) at this year’s NHS Confederation conference considered the keys to achieving integrated care over the next few years. The identified factors included: the importance of relationships; getting the right systems in place, worrying less about organisational boundaries (instead know who needs to be present); sharing strategic goals, governance arrangements and risks (focus on the bigger picture); and continued work at all of the above.
It seems to me that those HWBs, working at the place level (LA) have been piloting these local relationships and ways of working since 2013. As place-based working continues to be rolled out at a rapid pace across the different levels (neighbourhood, place and system – .pdf) in the health care system, the effective local work being undertaken by HWBs should not be overlooked and their experience of innovative joint working, capacity to build relationship and work to shared strategic goals has much to offer.
There is a clear need to learn lessons from previous integration initiatives and to carefully join up national and local policy initiates to avoid contradictions. Contributors to the LGA report suggest that national conditions in the healthcare system have “caught up with the job HWBs were set up to do – in terms of highlighting the primacy of place, and of a partnership of equals” and having identified the potential of HWBs at their outset – I remain hopeful that this is the case.