Are wellbeing boards working?
Giles Peel and Judith Barnes provide a progress report on the roll-out of health and wellbeing boards.
As we head towards April 2013, it is perhaps appropriate to take stock of where things stand with regard to health and wellbeing boards: are they having an effect in shadow form and are they working in practice?
The Health and Social Care Act 2012, among many changes, will transfer responsibility for public health to local authorities and require health and wellbeing boards to be established in upper and single tier authorities.
Health and wellbeing boards bring together local councillors, GPs from relevant clinical commissioning groups, the directors of public health along with directors of adult and children’s services plus representatives from Healthwatch and other appropriate organisations or people into a new form of decision-making body. They are there to influence the improvement of the health and wellbeing of the local population, encouraging the integration of health and social care services.
Together, their expertise should deliver a collaborative and targeted approach that meets the needs of the local population. To this end, the boards will direct the production of joint strategic needs assessments and the resultant health and wellbeing strategy. These should provide compelling direction to those who commission or decommission services.
On the face of it, things have started with a real sense of purpose. There are many examples up and down the country of boards consulting on their strategies and developing sensible assessments of local need. Sampling these strategies reveals documents offering accessible information on progress made as well as pinpointing exactly where future investment will be prioritised.
John Wilderspin, the national director for health and wellbeing boards, believes “their potential is starting to be fulfilled” and cites examples of excellent practice where they are already creating a new sense of purpose and challenging the former mentality of spending public money in health and social care silos.
It is not hard to see that this is evident, and we have come across areas where complex issues such as equality are being dealt with in highly imaginative ways - for example, with the gypsy and traveller communities in Doncaster - and are having a real impact. As you would expect, it is also apparent that some of the bigger metropolitan councils and London boroughs - Manchester and Lambeth, for instance - are highly organised in embracing the changes.
So, where are the challenges? The transfer of public health teams to local authorities, a process that has been happening slowly over time with co-location, but is now being formalised with ringfenced budgets and new lines of accountability, will change the emphasis. The health and wellbeing boards concept will require the very different priorities of public health to be considered, together with the provision of health and local authority services.
The creation of new interfaces between local authorities and the commissioning board (in the shape of local area teams), as well as the requirement for intelligence and data from CCGs supported by commissioning support units, may not be smooth at first. There will be a need to revisit the section 75 arrangements and to understand the functions that will transfer - the so-called “stocktake, stabilisation and shift” proposed by the Department of Health guidance on transition.
It will be interesting to see how the more holistic approach to decision making on public health outcomes, based around the local “place”, plays out in the context of public authorities that are in the throes of cutting expenditure to meet comprehensive spending review reductions and the proposed cuts - in leisure, youth services, libraries and education, to name but a few - are likely to have a direct adverse impact on health and wellbeing outcomes.
Arguably, the strategy should now be in place and understood so that it can feed into the imminent budget cycle for local authorities and direct the CCG commissioning plans for 2013-14.
There will be tough decisions to be made. Rather than cutting the leisure offering (that may increase obesity and lead to increased cardiovascular disease), perhaps there should be an appraisal of how leisure could be delivered more effectively - perhaps through creation of a leisure trust or more investment in alternative community-based leisure activity and the consideration of different ways to focus on outcomes such as social impact bonds and payment by results.
The developing relationships of CCGs and health and wellbeing boards are being scrutinised and these reveal a mixed picture. In some cases, there are very advanced relationships, with clinicians at the heart of discussions to develop joint strategic needs assessments and strategies, and, in turn, reflecting these seamlessly in their own draft commissioning intentions.
Another area where traditionally it has been harder to achieve full cooperative working is adult and children’s services, and of these the latter has been the most complex.
Safeguarding is also being examined thoroughly as part of the CCG authorisation process and many of these roads will lead back to health and wellbeing boards and their ability to influence better joint working between authorities and partners.
The next challenge will be the delivery of proper integration, a word that pops up in all health and social care documentation with increasing frequency. This can only happen if the boards can understand and influence the integrated provision of services, and not just the commissioning of them.
This is a huge issue in many areas, especially the more remote and rural ones where potential logistical challenges are greater, communities harder to reach and resources more scarce. Here, more than anywhere else, the improvement that clinically based commissioning is going to bring will need to be felt quickly.
The boards are also a change from the established norms of local government, in that they bring together elected members and officers (as well as others) on one board. This will not be without its own difficulties and new ways of working, especially around controlling the nature of discussion and debate, will have to be found.
There are also some governance challenges around the way in which binding decisions can be taken - who will be authorised to agree what, where and how; who can be held to account for what and how are these arrangements reflected in the constitution?
Last but not least, there is the direct influence of politics in the boards’ outputs. A CCG chair recently expressed the view that his governing body’s work with the local board was going well but that they all feared that behaviours would deteriorate in the run up to next year’s local government elections, with delays and failures of services being blamed on their side.
This is a challenge for health professionals in an entirely new way but must also be seen as an opportunity for all those involved in health and social care to demonstrate that they are doing this work for all the right reasons. We will watch with interest.
Giles Peel is an adviser, clinical risk and Judith Barnes is a partner and head of local government at DAC Beachcroft LLP.