The effectiveness of health and wellbeing boards will depond upon how well they are able to build relationships between their members, says NHS Confederation deputy policy director Jo Webber.
Clinical commissioning groups are not the only major new type of structure that will be set up as a result of the Health and Social Care Bill. Health and wellbeing boards will also be created to strengthen the link between health and local government.
The great strength of these boards is that they will be made up of representatives from organisations from across a local area, including clinical commissioning groups, councillors and officials, patient groups and public health directors. With this full range of expertise, health and wellbeing boards will set the strategic direction for improving health and wellbeing across their area.
If they get it right, people will benefit from services that are joined up and work together to tackle the root causes of ill health.
This great strength also presents the greatest challenge as people from different organisations with different working cultures and accountability structures will have to come together and agree a way forward on a range of issues that could cover anything from housing to hospital complaints. Without coordination in dealing with these issues, the great potential of the boards will be lost.
Relationships built over many years will be the key factor in determining how well the boards can hit the ground running. Where those relationships are not strong or do not exist, it is vital that local groups start engaging with each other. In recognition of this fact, the NHS Confederation has come together with the Local Government Group, the Royal College of GPs, the NHS Alliance, Solace, the Royal Society for Public Health, the Department of Health and the Association of Directors of Children’s Services to draw up some principles and rules of engagement as to how these boards should work.
These principles set out how strong local accountability and legitimacy, a clear shared sense of purpose and robust governance will be the building blocks for establishing strong working relationships as these boards set about tackling priorities including health inequalities and charting a course for health and wellbeing services through a period of extreme financial strain.
Empowering local people and achieving legitimacy
The basic task of health and wellbeing boards will be to manage the different mandates and accountabilities each of their constituent organisations bring to the board and produce a strategy for an entire area that everyone can agree on.
Some of the organisations will be accountable to more than one body. CCGs will answer to central government through the NHS Commissioning Board, patients and the health and wellbeing board itself. They will also have to consult on and publish an annual report. There is still a worrying degree of uncertainty about how this will work.
While greater clarity is needed for CCGs, overall this marshalling of accountabilities by health and wellbeing boards need not be as hard as it sounds. More to the point, without agreement, the simple fact is that health and wellbeing boards will not have the full support of local people, and therefore will not achieve their potential.
The starting point for coordinating all these different bodies in practice has to be robust governance arrangements that mean disagreements can be dealt with in a transparent way. Underpinning it all is the joint strategic needs (and asset) assessment, as it is the basis for the entire strategy and direction of the boards.
It is vital that the new boards learn from the best of what went before, when PCTs and local authorities were responsible for drawing them up, and involve local people properly in setting out strategies and holding the board to account for the outcomes they achieve.
Not only will this foster better decision making, it will create legitimacy and accountability for the board itself and its actions. This is going to be really important as public services will have to make and support some difficult decisions about how and where services are delivered. Some services will shut while others will have to concentrate and possibly move out of the area. Without legitimacy and accountability through proper governance structures and genuine public engagement over the strategy, these decisions will become impossible to follow through.
Displaying collective leadership
In such testing times, leadership is essential as the oil in the system that allows all the constituent parts to work together. But this leadership should not stop at the board. The boards are made up of local leaders themselves so leadership must be collective to be effective. These leaders will need to go out to their relevant local constituencies, communicate the need for change and make sure the strategies set by the board are followed through.
Tackling health inequalities
Health inequalities will be a priority and therefore will become a measure of how successful the boards are. Many of the issues that need to be tackled can only be solved by coordinated action. For example, one of the key issues for the NHS to crack is unregistered patients. Finding these requires close work with a wide range of local groups.
The final piece to the puzzle is outcomes. Accountability, strong governance, and leadership will only be effective at tackling problems such as health inequalities if there is a clear focus on what the boards want to achieve and what outcomes will be measured and evaluated. This requires a strong evidence base, coupled with a clear understanding of what resources are available to enact the board’s strategy. Progress must be monitored with robust data so that clear signals to act or change course are available should plans start to falter.
Building and maintaining strong relationships
Ultimately, the principles for making health and wellbeing work are the principles for making relationships between organisations work. By working jointly to identify priorities for health and local authority commissioning and to make best use of resources to improve outcomes, the boards have a real opportunity to address health inequalities.
The challenges ahead for local health economies as funding gets so tight are considerable. Relationships between the different organisations represented on boards will come under strain and they will need to be strong enough to take the pressure. It is vital that, where the links do not yet exist, bodies across the health and local government sector start engaging urgently to gain a shared understanding of these challenges and what can be done about them.
The principles drawn up by the NHS Confederation and its partner organisations reflect the commitment of the national organisations representing the proposed members of the health and wellbeing boards to making the new system work.
We would urge board members to follow suit and not simply wait for the invite to the first board meeting and come into these issues “cold”.