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Health and wellbeing boards and strategic commissioning

Health and wellbeing boards and strategic commissioning

17 March 2014

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Health and wellbeing boards have been fully operational for less than a year and have been important in strategic integration in commissioning 

Health and wellbeing boards have been fully operational for less than a year and have been important in strategic integration in commissioning 
Amid the sound and fury that accompanied the parliamentary passage of the Government’s controversial NHS reforms, possibly the one and only area of quiet consensus was about the role and value of health and wellbeing boards (HWBs). Having existed in their full operational form for less than a year, voices across the political spectrum are calling for them to be given a stronger role in overseeing the local integration of services. So what are the prospects of success for these new poster boys of partnership working and what are the implications for commissioning? Our survey earlier this year offered some clues. 
The Health and Social Care Act has introduced a vastly more complex and fragmented matrix of new organisations, roles and responsibilities. Commissioning is divided between CCGs (acute and community health services, NHS England [primary care services] and 152 local authorities (social care and public health). No one is entirely clear about how these will work together and locally health and wellbeing boards are the one and only place that brings together the key local partners. If the Boards didn’t exist they would almost certainly need to be invented – if only as ‘sense makers’, information-sharers and coordinators of separate plans and strategies. These kinds of partnership vehicles have existed before, usually with disappointing results. The aspirations for health and wellbeing boards are much higher – the ‘crucible for integrated care’ was how the NHS Future Forum described them – and they have important legal duties to produce an agreed health and wellbeing strategy, underpinned by a joint assessment of population needs, that will set the framework for local commissioning intentions. The good news is that respondents to our survey thought that working relationships between CCGs and local authorities were good and getting better. It is certainly encouraging that positive chemistry that is the glue of integration has withstood a demanding year of complex organisational change and mounting pressures on services and budgets. Nearly all have produced their joint strategic needs assessments and local health and wellbeing strategies. Respondents were optimistic that their local strategies would positively influence the commissioning intentions of CCGs and councils – but over three quarters of respondents thought their strategies would make little or no difference to the commissioning decisions of NHS England. These results do not suggest that NHS England was a significant or equal partner around the HWB table. There is unfinished business in resolving this aspect of NHS England’s role with its quality assurance and performance functions in relation to CCGs. Our ‘Time to Think Differently’ programme has highlighted the need to transform the entire model of care that reflects the needs of growing numbers of people who need long-term care coordinated across different services rather than single episodes of treatment in acute hospitals. There is a growing view that primary care in its current guise is not configured to meet this challenge, and it is hard to see how HWBs can plan the realignment of primary, community health and social care services without the full engagement of NHS England as a local commissioning partner. 
This begs a bigger question about how HWBs manage the potential tension between the duty placed on them for setting a strategic framework for commissioning with that of promoting integration. Many HWBs have interpreted the former role in a way that precludes provider involvement because of conflicts of interest. Yet promoting integration arguably cannot happen without providers being round the table. In our survey only a third of HWBs had NHS providers as members, although in fairness many HWBs say they are engaging with them in other ways. Many would go further and question whether commissioners are able to drive integration at all, pointing to its very limited achievements in securing major change to services. The best examples of innovation in integration both at home and abroad are almost always provider-led. 
These dilemmas might offer one explanation why most HWBs in our survey appear to be ducking some of the biggest and most pressing challenges facing their local health and care services, opting instead to adopt priorities about public health and health inequalities. The focus on population health is of course welcome, a firm riposte to cynics who worried that councils might spend the transferred budgets on parks and potholes not public health. But unless HWBs start to grapple with integration and some of its less popular consequences (on the shape and scope of local hospital services for example) their credentials to become system leaders – the ‘go to’ place for local decisions on big health and care issues – will be hard to take seriously. The HWBs do not have a strong hand to play – although their duties are significant their powers are limited, reflecting their status as a forum for partnership and collaboration rather than executive decision-making. 
Expectations of what HWBs should deliver will continue to rise. The first round of health and wellbeing strategies are being scrutinised by single issue charities and campaigning groups for signs that ‘their’ priority has made it. Politicians of all parties foresee them as having a bigger role, for example in overseeing single integrated budgets for older people, as recommended by the Health Select Committee, or as the commissioners of ‘whole person care’ along the lines outlined by Labour. There is much that can be achieved by evolutionary development of HWBs through strong relationships between local authorities and CCGs – this has been the foundation of the progress made thus far. But some of these loftier aspirations will call for a more fundamental reappraisal of their powers and duties and the kind of professional support and capacity they would need to be effective on a bigger stage. The Government of the day may struggle to find ways of giving the Boards a more powerful role without further organisational change to which there is current and widespread aversion throughout the NHS. In the meantime HWBs will quickly face some demanding tests of their effectiveness and resilience. The first is to sign-off local plans for their share of the £3.8 billion Integration Transformation Fund (ITF) by April next year. The national strings attached to this money are stringent – reducing hospital admissions and speeding up discharge, protecting social care services and introducing seven day working are some of the national conditions that local plans must satisfy. Bearing in mind that this is not new money, there will be some tricky issues about decommissioning or reducing existing services. Brokering agreement with CCGs about spending it on different things that offer a win-win for health and social care – and without destabilising local acute hospital finances – is a very big ask. The latest guidance is clear that these two-year plans must be set in the context of a five-year plan for the future of local health and care services. Far-sighted Boards is will see the ITF process as a stepping stone to planning with 100% of the total health and social care budget not just the 3% which the ITF represents. This is the prelude to an even tougher test which is engaging with the public about controversial changes to local health services where public awareness lags way behind professional and policy assumptions about the case for change. Is it really possible for Boards led by local authority elected members to resist the lure of political populism and lead rather than follow public opinion? This will demand a high calibre of local leadership and expose the need for local government and their local NHS partners to develop a much deeper mutual understanding of their fundamentally different cultures and ways of working. 
To meet these tests Boards will have to move beyond the hidebound traditions that accompany its status as a statutory committee of the local authority to more imaginative ways of engaging with stakeholders and local communities about the kind of health and care system that is sustainable and relevant to current and future needs. Effective Boards will explain honestly that not everything can be a priority and will see their primary modus operandi not as having formal meetings but developing a network of relationships with everyone who has a stake in the trade-offs between different options. An outward-facing role will also help Boards develop an asset-based approach to meeting needs that draws on the natural resources of individuals, families and communities.
But perhaps the biggest challenge of all facing the Boards is how far they can overcome the deepening national fault lines between a health care system that remains largely universal and free at the point of use and an increasingly rationed and means-tested social care system. The King’s Fund has established the Barker Commission to review whether the separate approaches to funding and entitlement for these services can be brought closer together. It may well be that the ultimate effectiveness of HWBs will hinge on much more radical policy shifts than those envisaged by the NHS and social care reforms. 

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