A local government simulation exercise provided a valuable insight into how health and wellbeing boards could - and need - to work in the near future. Hywel Lloyd and Helen Brown discuss the lessons learned.

The problem with carefully laid plans is that we often assume they will go smoothly and that people will listen and respond as we intend. In reality, key decision makers face multiple pressures, conflicting priorities and different views of “what’s best”.

By simulating change ahead of time we can explore the pressures, tensions, relationships and issues that must be navigated, then re-plan on a better informed basis.  

With the Office for Public Management acting as co-designers and facilitators, last year the Local Government Association ran a simulation of the future of local government. The health and wellbeing board was a crucial player in this simulated future, even if partners found it hard to agree on what it should prioritise.

Set in 2014, the simulation took place over two separate days and involved 100 senior managers and politicians, drawn from health, police, fire services, the private sector, voluntary and community sectors, and managers and politicians from all three tiers of local government. Participants were given detailed demographic, financial, performance and other data about a fictional but realistic locality and were asked to take on a job, or function, in order to complete a series of strategic tasks involving working with partners.

High ambitions

In the simulated future, health sector managers saw the health and wellbeing board as the pre-eminent local partnership. They were highly ambitious, and tried to explain to local authority colleagues that this could, and should, be absolutely at the centre of place-based strategy.  

For local politicians, the most important priority was the economy and the recession. Their attention was focused on jobs, on the private sector and on the local economic partnership, as well as on the relationships with the government that might spark local economic growth. The health and wellbeing board designed meetings and set up partnerships and consultations – but then, so did the newly elected police commissioner and all the tiers of local government. 

During the first phase of the simulation, every agency wanted key decision makers to come to “their” partnerships and no-one had the time to respond. Health managers felt angry that important issues of health and wellbeing were being neglected by the wider community and by local government in particular.

The leading health players decided to do something about it, and approached the person appointed as leader of the county council, persuading him of the importance of visible political leadership. He agreed to chair the health and wellbeing board, which gave the profile and leverage it needed.

Challenges in moving the health and wellbeing board into action remained, however. The language and culture of the sectors was still very different.

A key finding from the event was that the priorities of health professionals may not always fit well together with those of other local partners without an intentional and powerful process of sharing understanding and knowledge in order to build future joint action.

For local authority politicians and managers, the health and wellbeing board created a space to tackle mental health, obesity, drug and alcohol addiction and the care, preventive support and reablement of older people – Cinderella services in the past. 

In the simulation, some participants felt that their health colleagues were too focused on acute provision and on their own vertically integrated approach. 

Health participants were trying to respond to a radically changing local government landscape, with smaller commissioning authorities, far more outsourcing and services such as social care being spun into employee-owned mutuals.

Transfer challenges

As the county council transferred services and decisions to local communities, this created new challenges. These included thinking about health provision in relation to smaller areas, understanding the role GPs can play in neighbourhoods, and integrating primary care into local networks of provision.

Questions of scale were ever present, as participants considered inevitable tensions between localisation of some services, and centralisation of others. It was evident that “commissioning” still means different things to people in different parts of the local government and health systems. The local authorities took different stances: some were very hands-off, expecting the market to manage itself, while others wanted to manage the market carefully, participating in the whole of the supply chain.

We can anticipate similar variation between clinical commissioning groups. As health and wellbeing boards create a local strategic framework, choices will follow about what commissioning strategy to adopt. 

In the months following the simulation, OPM has been working with several health and wellbeing boards across the country. Each board is different and much remains uncertain, so the approaches being developed are both provisional as well as emergent.

It is clear that the role of local elected politicians will be an important one. Local councillors will have new responsibilities and accountabilities for health, and local politics will change as a consequence. Councillors, instead of lobbying from the outside, will be engaged in thinking about the trade-offs between health needs, and will find themselves exactly where local needs, or the views of their voters, collide with government priorities and targets. 

It will be important that the health system engages early and well with the concerns and perspectives of local politicians. Councillors will be on a steep learning curve, and health colleagues, especially GPs, need to find the time to help them build up their working knowledge of the health system. 

There are, of course, exciting opportunities to rethink services across boundaries, and to find better and cheaper solutions to the health problems in all of our cities, towns and rural areas. 

Health and wellbeing boards are obviously not starting from scratch. In many areas, joint commissioning is long-established and health and social care professionals work effectively hand in hand. What is perhaps surprising is that the gap between health and local authority perspectives remains as wide as it sometimes does.

Health and wellbeing boards provide an opportunity to close that gap. They are a place where the priorities and perspectives of health professionals, and the underpinning evidence, can be brought together with the perspectives and needs of local communities.

To make the most of this opportunity, the LGA simulation suggests that, on all sides, we need to work on building the foundations for a successful future. We should be prepared to learn together: to build strong relationships and create the shared understanding that will enable all the resources at hand to be used to achieve the best outcomes for local communities.