Health and wellbeing boards have been seen by local government as having huge potential to bring much needed coherence to a fragmented system. Establishing robust and effective partnership boards will be challenging, but councils and their partners have been taking on the challenge of setting up boards in anticipation of forthcoming legislation.
Across the country, local authorities are taking a variety of approaches in setting up health and wellbeing boards. Among the issues they are tackling are the remit and appropriate membership of boards, the extent to which they will be involved in commissioning, what the focus of their activities will be, how they will carry out performance management and how they will engage with stakeholders, including service users and patients.
This blog provides case studies and analyses a number of stages in the development of boards, key messages for each stage and questions those involved may wish to ask themselves at each stage.
The LGA’s healthy communities programme was interested in how local authorities and their health partners around the country are starting to develop health and wellbeing boards (HWBs) in advance of legislation and, therefore, in advance of knowing exactly what the powers and duties of the boards will be. They asked us to do a general survey of how local authorities were progressing the formation of boards and to carry out more in-depth interviews in a range of local authorities.
These case study areas were chosen to cover a geographical spread, rural and urban areas, different political administrations and single tier and two-tier areas. Based on our web-based research, interviews in the case study areas and information provided by government regional offices charged with supporting the development of boards, we were able to form what we believe is a representative picture.
We have drawn together a largely web-based resource with a number of components:
- a discussion with examples about the main opportunities, challenges and solutions involved in setting up boards and key messages based on these findings
- questions to consider when preparing for HWBs at each stage of the journey
- case studies showing the journeys of nine boards from around the country
- a summary of national and regional resources available to support implementation
Our research suggests that there are a number of challenges common to embryonic HWBs, whatever their local circumstances:
Membership and governance – how to balance the need for inclusiveness with the need to remain small enough to function effectively and take strategic decisions; the respective roles of the HWB, health scrutiny and LINks/HealthWatch; constitutional issues in setting up a new council committee with officer and non-council members. We were impressed by the number of boards which are chaired by the council leader or by a senior cabinet member – an indication of the seriousness with which they are being taken and perhaps of the fact that councils see the boards as more “heavyweight” than some existing health partnerships.
Skills and preparation – how to define and develop the skills members will require to run an effective board, including recognising and addressing the different organizational cultures of board members.
Defining the board’s role – whether to take an arm’s length high-level strategic approach or to take on a direct commissioning role, eg in joint commissioning; relationships with other local bodies and partnerships; how much of the children’s agenda to cover and what relationships should be with existing Children’s Trusts; how to address safeguarding issues and take a lead in embedding an effective approach to safeguarding across the local public sector.
Focusing on priorities – how to ensure an appropriate balance across health, public health, social care, health improvement, the social determinants of health and tackling health inequalities; how to develop a common understanding of wellbeing and address mental health issues; how to balance their focus on local and national priorities.
Tackling problematic issues – what to do if partners disagree, for example of clinical commissioning groups seek to pursue a narrow medicalised approach to health or if there is political opposition to service reconfiguration; how to deal with pressures arising from the economic and political climate.
Boards are addressing these challenges in a variety of ways. In some areas, a long period of preparation has deliberately been chosen before even an informal board is set up. In others, partners have decided to set up the board and carry out member development as part of its early activities. In general, we identified five stages in the journey towards full board establishment – the resource gives a number of key messages for each stage and questions boards may wish to ask themselves in moving to the next stage. The stages are:
- Preparing for the board – key features included the involvement and commitment of senior officers; the exploration and mutual increased understanding of councillors and CCG clinicians of each other’s roles; and agreement of how to undertake on-going engagement with a range of stakeholders including patients and service users. A number of boards, with the assistance of external consultants and/or regional offices, had undertaken scenario exercises, looking at different possible challenging situations such as budget-setting and service reconfiguration, to understand what role the board and individual members might play in such situations.
- Forming the board – one difficult issue has been whether to confine membership largely to commissioners or whether to include other stakeholders, such as voluntary and community organisations. Some boards have decided to involve NHS acute provider trusts. Others have ruled this out as setting up a possible conflict of interest and/or as favouring one out of a number of possible provider groups. Boards are well aware that if they are seen as “just another council committee”, they are unlikely to gain the commitment of NHS clinical commissioners. The NHS Confederation has drawn together, with the assistance of partners from the NHS and local government, a set of “operating principles” for HWBs which it hopes will help address this issue (see links).
- Developing work programmes, priorities and commissioning – most boards in the case study areas are undertaking prioritisation exercises with a view to shaping their work in the short term, but also feeding into the more extensive work they are doing to develop Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies (JHWS). Boards are also discussing any sub-structures they may need and what their precise role will be in relation to commissioning and joint commissioning.
- Developing JSNA and JHWS – the areas we spoke to are taking the opportunity to review their JSNAs to ensure they are “fit for purpose” in providing a genuinely useful tool on which to build health as well as social care commissioning. Some have begun to develop JHWS based on their JSNAs, others are working with and adapting existing health strategies – all are conscious of the need to take the “life course approach” to health advocated by Professor Marmot in his report on addressing health inequalities.
- Review, performance and looking forward – this will be a complex issue for HWBs, as they will need to find ways of assessing their own performance and their contribution to improving health and wellbeing in their area, as well as developing and agreeing an outcomes-based performance management framework for monitoring the work of health, public health and social care commissioners and assessing it against the outcomes defined in the JHWS, with appropriate reference to child health and safeguarding.
At present, the executive summary of our research and a short version of the case studies we undertook are available on the Local Government Group website (see links). The full resource will be available on the website shortly.
We were struck by the variety of approaches to health and wellbeing boards that we discovered across the country. There is considerable variation in membership, terms of reference and remit, sub-structures, approaches to stakeholder and service user engagement and the way boards carry out their business. It will be interesting to see if these approached begin to converge if and when the legislation is on the statute books.
At the moment it is too early to tell whether health and wellbeing boards will become the local powerhouses and drivers of health improvement and reductions in health inequalities that councils hope for, or whether they will become the tokenistic talking shops sidelined from any real decision-making that some current health partnership boards have become.
Much will depend on the energy and commitment that senior council Members and officers put into the boards and the extent to which they can impress on clinical commissioners the need to hold themselves accountable to their communities through the democratic system.