It seems a lifetime ago that prime minister David Cameron described health and wellbeing boards as being central to his vision for integrated health and social care.
The idea of HWBs was almost universally welcomed and emerged not only unscathed but strengthened during the furore surrounding Andrew Lansley’s NHS reforms, giving local government a far larger role than was originally envisaged. An organisational lovechild of coalition politics, HWBs embodied, as ex-Financial Times public policy editor Nick Timmins explains in his account of the 2012 Health and Social Care Act, the Liberal Democrats’ endless desire for a bigger role for local government.
This year marks their sixth anniversary (seven if you count the shadow year in 2012). Much water has flowed under the bridge and the currents of policy thinking are now taking a completely different direction, with sustainability and transformation plans evolving into partnerships (STPs) and now integrated care systems (ICSs); a Long Term Plan for the NHS with £20bn of new money; and proposals by NHS England and NHS Improvement for legislative changes in order to support the new policy mood music of collaboration – changes that would unravel many of the key features of the 2012 Act that brought HWBs into being.
But there has been little national discussion about where these policy shifts leave the role of HWBs. The NHS Long Term Plan is virtually silent about their existence. The proposals for legislative change refer to improving joint working between the NHS and local government and how councils might be part of new joint committees between local NHS providers and commissioners. HWBs get just one mention in the document, acknowledging that the NHS will need to “continue to be a full and active partner” in them.
The apparent invisibility of HWBs on the radar of NHS policy-makers reflects deeper and longstanding issues that have bedevilled the ability of the NHS to engage effectively with a major external partner that is not part of itself. That HWBs are a statutory committee of the local authority causes many in the NHS to see them as someone else’s meeting that they attend rather than a genuinely joint partnership body. Even so, it is disappointing that the thinking behind the NHS Long Term Plan and subsequent legislative proposals appear to overlook the statutory duties placed on HWBs to produce a joint strategic needs assessment and a joint health and wellbeing strategy about how those needs will be met. For the NHS to consider a different parallel set of arrangements to oversee population health is illogical and would leave HWBs swinging in the wind unless their role and contribution is clarified.
This goes beyond the NHS Long Term Plan. To paraphrase TS Eliot, in the turning world of multiple integration initiatives over the years, a fixed point is the need for some kind of local partnership forum at local authority level. If HWBs didn’t exist, something like them would need to be invented (as evidenced for example by requiring them to sign off local better care fund plans).
Work from the King’s Fund on the experience of STPs and the emerging ICSs has shown very clearly that integrated care and population health cannot be delivered without the full and meaningful involvement of local government. Parity of treatment with the NHS is vital as the Local Government Association has argued. Much of the work has to take place on a smaller geographical footprint, with clinical commissioning groups and local authorities a bottom-up engine room of change. In places as different as Wigan, Leeds, Lambeth and Coventry and Warwickshire, HWBs are working hard to fulfil this role. The issue is not whether a local partnership vehicle is required but what form should it take, what it should do and who should be on it.
So clarifying the future role of HWBs ought to be a central consideration in the review of NHS legislation. It offers a timely opportunity to take stock of the mixed experience of most boards and learn from those that have been most effective, sending a clear signal that the NHS is committed to looking beyond its own boundaries and forging a meaningful partnership with local government.
There are several options a review of legislation might consider, in collaboration with local government. At the very least it should clarify how the existing statutory duties of HWBs to promote integration would fit within any new joint committee arrangements. It could rebalance the membership of the boards so they become a genuinely joint forum with local NHS partners, and embrace providers as well as commissioners – important given that many HWBs see themselves primarily as overseeing strategic commissioning and exclude providers from membership.
A more radical option might be to recast HWBs as legal entities in their own right, as for example Scotland has done with joint integration boards, thus resolving legal uncertainties about local government’s ability to commission health services.
But the overriding challenge is to come up with options for local governance that strike the right balance between clear accountabilities and local flexibility in reflecting different needs and geographies, ensure the effective engagement of local government, providers, primary care networks and the third sector and clarify the relationship between re-purposed HWBs and the wider footprint and functions of ICSs.
Richard Humphries, senior fellow, The King’s Fund