Giles Peel looks at the ongoing development of health and wellbeing boards, and their burgeoning relationships with clinical commissioning groups.
Among the considerable furore surrounding the Health and Social Care Act, one area that has not received anything like the same coverage has been the emergence of health and wellbeing boards. Given huge publicity at their concept launch, around 140 HWBs (out of a total community of 152 local authorities) are now being developed in a variety of forms and at different levels of sophistication. As they get to work they are expected to engage with the larger population of clinical commissioning groups.
With this changing picture it is hard to make a firm statement as to how well matters are progressing, but there are critical challenges facing these organisations:
- We are seeing a meeting of two new mindsets – with clinicians in a commissioning role on the NHS side and social services/public health officials taking a broader health interest on the local government side. This is already leading to innovative thinking in developing new programmes; more of this later
- Timing is crucial, with local government now through the worst of its cuts and the NHS still with considerable organisational turmoil in the background and significant efficiency targets to achieve. Tolerance will be needed from both parties
- Co-ordination of policy and care delivery between the two sectors is a concept that has never really been achieved in practice. There are now new attempts to make it work, particularly in the area of pooled budgets, and must be delivered in front of demanding political and public audiences
- These fledgling relationships (both sectors freely admit they have much to learn about each other) will be altered significantly once HWBs assume their scrutiny role and start to pass judgement over CCG performance against joint strategy
- It is clear that common areas for development are already being considered, and these include hospital discharge management, A&E admission reduction, community healthcare in the home, mental health support services and learning disability support services. For all of these, the watchwords are early intervention and prevention.
Given these challenges what is happening on the ground? Well to begin with there is considerable enthusiasm for change and a number of pilot projects have attracted early publicity.
For example, the Kent Health Commission set up November 2011 has worked on a pilot project to join up services in the interests of patients. Using a CCG and a district council, the stated intention is to shift 5 per cent (or some £59m) of activity from acute to primary and community healthcare. The whole project has been characterised by strenuous efforts to involve and engage a wide variety of stakeholders.
In Newcastle, the local PCT and city council have established a multidisciplinary team to deal with issues arising from hospital discharge and homelessness. In this work the targeted use of appropriate housing allocation can improve independence prospects for more vulnerable patients, thereby reducing the likelihood or readmission to a hospital setting. The key aspect of this is the innovative co-ordination of health and social care staff to address the problem at both ends and at the same time.
In London, Lambeth is one of a number of local authority organisations that are piloting a neighbourhood view of future public services. This will not only build local capacity for the future but critically it also helps to build up a working community understanding of the types of problem and most appropriate solution for delivering health and social care services on a joint basis.
So progress is being made and early signs encouraging, but what is next for this area? Some new challenges loom ever larger and these will shape the success or otherwise of the next phase of development.
- CCG authorisation, and its rate of progress, will inevitably shape the market into which HWBs must exert influence. This will create more problems if it is not settled quickly
- Other established organisations must and will have an influence. For example clinical networks have much to offer the debate on service redesign and yet these have not really been engaged in a significant way in many areas to date
- Integration of clinical pathways is testing enough for the NHS at present, and yet the local government perspective must start to have an influence on this thinking now
- Both sectors will need to get to grips with the notion of effective public engagement and consultation. This must be more instinctive, more inclusive and less adversarial.
Given the latest legislative changes, for CCGs there will be 12 new general duties and for HWBs a duty to encourage integrated working. When the remaining relationships between these two and the National Commissioning Board are also factored in, a complex picture starts to emerge, and there is no doubt that this will not be an easy first few months for these young organisations.
In summary there is plenty of enthusiasm and a willingness to learn on the part of CCGs and HWBs. Expectations will be high but given the right support, the early signs are encouraging for this new axis of commissioning power.