The NHS Future Forum demands health and wellbeing boards be ‘crucibles of integration', but will they live up to this expectation – or have 152 talking shops just been spawned? Rebecca Norris investigates.
Compared with other aspects of the health bill, health and wellbeing boards have had a positively serene start in life. There was initial controversy when the 2012 white paper proposed scrutiny should form part of the board's remit, but it's now been decided to keep this role within the local authority more generally. The other big ‘headline' for health and wellbeing boards has been the movement of public health out of PCTs to local authorities. But there is still much to be worked through on this.
Transference of directors of public health is yet to happen in some areas, and guidance is still being drafted on where responsibilities will lie between local authorities, the NHS and the new Public Health England. Public health budgets due out at the end of this year are also proving a very thorny issue, with only 42% of the budget set to go to local authorities.
Yet despite big gaps in key details, there has been strong initial enthusiasm on the ground for health and wellbeing boards.
All local authorities, apart from a handful, have set up shadow health and wellbeing boards with ‘great enthusiasm', says David Rogers, the Liberal Democrat chair of the Local Government Association's community wellbeing board and a councillor on East Sussex County Council. In his own area, he had found all CCGs ‘very enthusiastic about the opportunity and wishing the whole legislative process was done and dusted so they could get on with it'.
Mr Rogers says by now, health and wellbeing boards should be meeting regularly in shadow form and be working on ensuring their joint strategic needs assessment (JSNA) was fit for purpose in line with new Department of Health guidance.
This enthusiasm comes from a recognition by all parties in health and social care that things cannot go on as they have done before. The demands on the NHS and social care are growing, with more older people and social care systems at breaking point. But attempts at joint working between health and local authorities are nothing new. So what, you might ask, will be different this time, other than a CCG person sitting where the PCT once sat?
Bringing JSNAs to life
JSNAs have been around since 2007. But only a third are estimated to have really challenged how services are delivered. Most JSNAs tell people what they already know and have become an end in themselves.
From April 2013, the boards will take over the production of JSNAs and face a new duty to draw up a joint health and wellbeing strategy (JHWS). The assessment of quality and outcomes will include looking at how much a commissioning group has contributed to the outcomes prioritised in the JHWS.
Dr Joe McGilligan – chair of EsyDoc CCG in Surrey and, uniquely, co-chair of Surrey County Council's health and wellbeing board – says he sees boards as a way to bring together the council and healthcare ‘on an equal footing' to bring the JSNA ‘to life'.
‘[Health and wellbeing boards] will be the place where strategic plans are drawn up and where the big-ticket items can be discussed,' he says. ‘They will even be the place to discuss bus services to get patients to and from hospitals and clinics.'
A further enhancement of JSNAs could be a requirement in the bill for the NHS Commissioning Board to send a representative to participate in the preparation of the JSNA and JHWS. This could be useful to nip any perceived problems with CCG commissioning plans in the bud before they escalate into disputes, and to add a further NHS voice to boards dominated by councillors.
The health and wellbeing board will also be legally bound to ‘encourage' commissioners to work in an integrated manner and ‘provide such advice, assistance or other support as it thinks appropriate' to encourage pooled budgets under existing ‘section 75' flexibilities [of the 2006 NHS Act], which allows health and social care to pool budgets to fund initiatives.
To enforce their integration duties, health and wellbeing boards will have the power to refer concerns about CCG commissioning plans to the NHS Commissioning Board if they believe GPs haven't paid enough regard to the new JHWS. This dilutes ministers' original intentions in the bill to give health and wellbeing boards a veto over commissioning plans.
However, the DH has also accepted a Future Forum suggestion that the NHS Commissioning Board should use its authorisation process to test the will and capability of CCGs to collaborate in the design and commissioning of more integrated care journeys for patients before granting them their full statutory powers.
So while the legislation and governance gives the JSNA more ‘teeth', funding and culture will still play a big part in how much health and wellbeing boards achieve.
Distraction or focus?
John Wilderspin, the DH's director of health and wellbeing board implementation, admits board members are in danger of being distracted because of the ‘massive' financial pressures on leaders in the NHS and local government. He recently blogged that some shadow boards were overcoming this by ‘using the current pressures as a focus… to try and find innovative solutions'.
‘Some have focused on how they use the social care funding – £648m this year – allocated to PCTs to try to stabilise A&E admissions or delayed discharges,' he says. ‘Others are using the foundation trust application of their big NHS providers as an opportunity to think through the best local configuration of services'.
A typical health and wellbeing board discussion will be whether the NHS should shoulder more social care costs given the potential to reduce pressures like emergency admissions later down the line. However, the bill shied away from introducing any radical integrated funding streams. Health and wellbeing boards must instead rely on existing section 75 flexibilities.
Mr Rogers says he does not envisage authorities devolving entire commissioning streams to health and wellbeing boards overnight: ‘It'll be an evolutionary process.'
He adds that chief officers and councillors have been making difficult decisions for several years now as a result of reductions in social care funding, and this will give them empathy with CCGs' own duty to meet the Nicholson 4% efficiency challenge: ‘They are used to taking hard and unpopular decisions. CCGs just need to be prepared for constructive discussions about what should be different in a locality.'
Dr McGilligan quips that ‘everyone thinks their budgets are wrong' but ultimately, ‘there is only one public pound and it can only be spent once – whether that be a health pound or a social service or county or borough council pound'.
On the same page?
For Dr James Kingsland, national GP commissioning clinical network lead, a key difference between the old and the new will be the opportunity to create new services to meet patients' needs rather than trying to marry existing ones together. The pattern in the past was for GPs recruited as PCT medical directors to learn the ‘jargon and language' of management and then come back to tell GPs how difficult it was to manage the local NHS, he said: ‘If we have [CCG] people going in to joust with the local authority and then come out to the CCG and say "you don't know how difficult it is to be a councillor", then that won't be clinical engagement. A hierarchical structure is not the only way to deliver change – it will come from the people who receive the service and who deliver it.'
While it is ‘inevitable' some ‘tribalism' will remain, he is hopeful that health and wellbeing boards offer CCGs an opportunity to tackle previously intractable issues.
In this new era of co-operation, Dr Kingsland argues it will no longer be good enough ‘to pass the buck back to the local authority and say ‘[the NHS] hasn't got an anti-smoking service that treats the housebound, seriously ill patient'.
‘We need to say, let's create a service around those sorts of patients – which means that if a service is required, you don't have to write in triplicate. Instead, it's a case of the CCG having a mechanism through the health and wellbeing board to say, what this person needs is a health visitor review, occupational health review, a social care review and a benefits review, as well as the GP review,' Dr Kingsland says.
Dr McGilligan says he thinks ‘very few plans' should ever need to be referred to the NHS Commissioning Board ‘because everyone will be striving for the same goal'.
Time will tell whether the boards can keep their focus on what they are trying to achieve together for patients, while the health and social care players grapple simultaneously with the big financial demands ‘at home'.
Rebecca Norris is a freelance journalist
health and wellbeing board players
Could see board as
• means of getting advice on needs of population
• early sounding board for commissioning plans
• opportunity to jointly commission services
• ganged up on as in a minority (legislation allows a representative from each CCG)
• pressure to hand over large cash sums to social care
• bewildered by local authority jargon
• overwhelmed by number of meetings
Director of adult social care
Could see board as
• a forum to argue the NHS should invest more in preventive and rehabilitative social interventions to bring savings ‘downstream'
• source of funding – funding nationally for social care has reduced by £1bn since 2010
• the board needs to recognise how bad things have got in social care, particularly for older people
• that the intolerable pressure on carers needs to be addressed
Director of children's services
Could see board as
• means to embed policies to protect vulnerable children into all commissioning plans to ensure they do not fall through gaps
• CCGs should fund and continue the past requirement on PCTs to have a named child protection lead
• increasing demands following Baby P case and 25% reduction in central funding,
• frustration at children's public health being more fragmented
Director of public health
Could see board as
• an opportunity to flex muscles under boosted status
• vehicle to challenge uptake of immunisations and screening
• the free public health advice they are obliged to give CCGs could be at odds with private commissioning support organisations' attempts to save money
• that the ring-fenced £2.2bn public health budget must remain ring-fenced
Local Healthwatch rep
Could see board as
• opportunity to represent the patient voice
• under-resourced – HealthWatch funding comes from cash-strapped councils
• not sufficiently independent – they will exist as a committee of the CQC and their local authority funding means they are less able to criticise the hand that feeds
• their remit to promote patient choice pushes them towards having more alternative providers in the local system
Could see board as
• making commissioning decisions locally accountable
• has the final say as bill allows local authorities to appoint as many elected members as possible
• partnership working is finally being taken seriously
• a need to behave in a constructive manner now bill amendment removes scrutiny role from health and wellbeing boards
NHS Commissioning Board rep
Could see board as
• means to nip in the bud any perceived problems with commissioning plans
• add a further NHS ‘voice' to boards dominated by councillors – the Board does not have to be represented on health and wellbeing boards, but must participate in preparation of JSNAs and JHWSs
• under scrutiny – health and wellbeing boards can request the Board to send a representative to discuss issues relating to those services it directly oversees
Will Health and Wellbeing Boards succeed?
Factors that will help health and wellbeing boards succeed in delivering more integrated care
Direct access to council directors – avoids unnecessary red tape, mandate for things to happen ‘from the top'
Legal requirement to ‘encourage' integration
Power to refer CCG to NHS Commissioning Board if felt not giving sufficient importance to JHWS
Earlier sounding board for radical, controversial, or unpopular decisions.
A united voice when facing press and public or scrutiny from above
NHS Commissioning Board ‘representation' in drawing up of JHWS and JSNA
Health and wellbeing board council elected members different to those councillors sitting on the local authority health scrutiny committee
Adherence to JHWS to be part of quality and outcomes framework
CCG authorisation process to test will and capability of CCGs to collaborate in the design and commissioning of more integrated care journeys
Factors that could hinder success
Large potential number of meetings required
Cuts to social care funding and QIPP challenge resulting in ‘tribalism'
Non-integration of health and social care budgets in the bill
CCGs feeling outnumbered/ganged up on because in minority
Nervousness by elected members of making radical/risky moves for fear of political fallout