Place-based developments in health care: What can we learn from health and wellbeing boards?
This article was originally published in On Primary Care, a collection of essays identifying the challenges and opportunities facing policymakers today in the UK primary care sector.
In this blog, Dr Anna Coleman from the Health Organisation, Policy and Economics (HOPE) group, emphasises the importance of Health and Wellbeing Boards (HWBs) as integral functions in our Health and Social Care System. Following the publication of the White Paper written by the Department of Health and Social Care in February 2021, the article features a brief update suggesting the need for further clarity to the proposals put forward.
- While many support the idea of integration within the Primary Care System, clearer guidelines relating to the organisation and management of such partnerships need to be addressed.
- Place-based working is extremely valuable when creating positive relationships and collaborations at all levels across the system.
- Governing powers can learn from the benefits of Health and Wellbeing Boards, such as their ability to work across organisations and sectors – helping with the implementation of policy initiatives across primary care settings.
2021 update:
The proposed White Paper sets out the case for a new legislative framework to facilitate less competition and greater collaboration within the NHS and between the NHS, local government and other partners. Two existing duties to cooperate will be replaced by a duty to collaborate across the NHS and local government. Local government must remain accountable to the pubic (democratic accountability), while also holding local NHS organisations to account via overview and scrutiny powers and duties. However the proposed extension of power to the Secretary of State for Health and Social Care could undermined the latter.
There is a need for clarity relating to the respective roles and responsibilities of the proposed Integrated Care System (ICS) NHS Statutory Bodies and the ICS Health and Care Partnerships. This includes how they will relate to health and wellbeing boards (HWBs) and other integrated activity at local level. Current good practice, such as the work carried out by HWBs to address health inequalities, should not be lost in any changes made.
Many commentators, including the Local Government Association (LGA) support the emphasis on freedom for local areas to develop their own place-based partnerships; building on existing health and wellbeing boards and local delivery partnerships with the Better Care Fund becoming a key component. However, it is currently unclear how such partnerships will be held to account, and by whom. The proposals currently lack detail as to how decisions will be made, how disputes will be resolved and how conflicts of interest will be avoided, either at Place or System level. These issues are vitally important and must be clarified urgently.
Further proposals in the White Paper focusing on the joint commissioning arrangements and joint appointments across the NHS and local government, suggest that learning from the past is needed and I would urge policy makers to utilise knowledge from the operation of Health and Wellbeing Boards, in the context of future effective collaboration.
The following piece was written before the Department of Health and Social Care (DHSC) published the legislative proposals for a Health and Care Bill in February 2021, and featured in the Policy@Manchester collection On Primary Care (2020):
Health and wellbeing boards (HWBs) continue to be an integral part of the current health and social care system in England. They bring together a wide range of representatives from local organisations, build on local partnerships, and support joint working across sectors and organisations locally.
HWBs: the new system stewards?
The Health and Social Care Act 2012 gave HWBs specific functions, including the preparation of the Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies, both duties of local authorities and Clinical Commissioning Groups (CCGs).
With local responsibility for the strategic oversight of health care developments, and links with services which can have an impact on wider determinants of health, HWBs initially seemed ideally placed to become the new system stewards.
HWBs are sub-committees of upper-tier and unitary local authorities, made up of representatives from services across the NHS, public health, and social care, as well as children’s and other local services, including police, fire, voluntary and local healthwatch.
This configuration facilitated the potential for local cross-organisational work at a strategic level and provided the opportunity for longer-term development of collaborative working across the NHS and local government.
In 2016, we identified an ongoing struggle between local agendas, such as tackling inequalities, and central government priorities, such as integration, which suggested HWBs may only be a part of the solution. We recommended that they focus on their local system oversight and coordination roles in parallel with the development of local joint working practices.
Integration is seen by many as the solution to joint working, but the wider context of austerity and budget cuts, especially in local authorities, does not facilitate this. Additionally, constraints regarding organisational, professional and accountability rules and contexts continue to be problematic.
Our research suggested the role of HWBs remained unclear but had great potential to add value to and steer the local system.
Learning from the past
Partnerships (and other forms of integration) have long been mooted as a prerequisite for tackling complex issues that require a multi-agency response. Historically, however, they seem unable to break free from the silo-based structures which govern the organisation and delivery of many UK public services.
In 2019 I pointed out that there was potential to learn from HWBs in the context of developing integrated care systems (ICSs), evolving from sustainability and transformation partnerships (STPs) and suggested:
‘The new place-based system of working [following the publication of the 2019 NHS Long Term Plan] could usefully learn from [HWBs] how to operate successfully across sectors and organisational boundaries, include an element of democratic accountability, and create strategic partnerships of equals’.
This followed the publication of a report by the Local Government Association (LGA), ‘What a difference place makes’, which stated that ‘the original objectives for HWBs were as relevant to the new NHS landscape as they were in 2013, if not more so’. Their report highlighted 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 King’s Fund report in 2019, examined the ‘role of HWBs, and local government more broadly in relation to the emergence of ICSs’. It suggested that: ‘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’.
‘Delivering together’, a paper from the NHS Confederation’s ICS network and solace in 2020, also pointed to the potential confusion and overlap of roles and responsibilities in the developing system:
‘HWBs have statutory responsibilities that include significant elements of the non-statutory roles of ICSs. Specific examples include oversight of commissioning plans, joint strategic needs analysis and responsibility for developing local strategies for health and wellbeing. This includes local authority-commissioned services such as social care and public health. Local authorities also have overview and scrutiny committees or sub-committees for health and care. These pre-date the Health and Social Care Act 2012 and can make recommendations to NHS organisations or central government, but do not have powers to require change’.
However, The King’s Fund report highlighted the unique input local government could potentially have by 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.
HWBs, working at place level, have been piloting these local relationships through different types of leadership and collaborative ways of working since 2013, building relationships and associated trust within local systems.
As place-based working continues to be rolled out at a rapid pace across different levels (‘neighbourhood’, ‘place’ and ‘system’) in the health care system, the effective local work already carried out by HWBs should not be overlooked. Indeed, their experience of innovative joint working and work to shared strategic goals has much to offer.
Implications for ongoing policy development
‘Designing integrated care systems (ICSs) in England’, published in 2019, broadly set out the different levels of working within the developing ICSs, describing their core functions, the rationale behind them and how they will work together. This made only brief mention to HWBs, stating ‘ICSs will be expected to work closely with them, especially at the place-based level’.
By not highlighting the potential of HWBs in the local system, or detailing how these might actually operate together, is this a missed opportunity?
Contributors to the LGA report suggested that national conditions in the health care 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’.
We should learn lessons from HWBs. They operate across organisations and sectors to facilitate the implementation of policy initiatives and help avoid contradictions and unexpected outcomes. One of the biggest problems with HWBs was lack of clarity about their roles and their lack of statutory authority. The way that ICSs are being established and operated could well be duplicating these same issues and consequent problems.
‘Delivering together’ goes further, voicing some of these concerns around the lack of clarity over roles and relationships, confusion over the interaction between the objectives of ICSs and other organisations and existing statutory duties, and uncertainty over the role and significance of ‘place’. It makes a plea for more careful thinking both nationally and locally as policies are rolled out.
The current speed of implementation of policies such as ICSs and primary care networks, following the publication of the NHS Long Term Plan in 2019 and associated initiatives at different levels, means we are in danger of losing the important lessons of history and the potential to build on what works in what context.
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