health and amy galea wellbeing boards claire …...the nhs operating framework for 2012/13 describes...

1 © The King’s Fund 2012

Health and wellbeing boardsSystem leaders or talking shops?

Authors Richard Humphries Amy Galea Lara Sonola Claire Mundle April 2012

Key messagesn ThecreationofhealthandwellbeingboardsisoneaspectoftheNHS

reformsthatenjoysoverwhelmingsupport.Theboardsoffernewandexcitingopportunitiestojoinuplocalservices,createnewpartnershipswithGPs,anddelivergreaterdemocraticaccountability.

n Boardsneedtobeclearaboutwhattheywanttoachieve.Wefoundpotentialtensionsbetweentheirroleinoverseeingcommissioningandinpromotingintegrationacrosspublichealth,localgovernment,thelocalNHSandthethirdsector.

n Despitetherhetoricoflocalism,manyshadowboardsareconcernedthatnationalpolicyimperativeswillover-ridelocallyagreedprioritiesandareuncertainabouttheextenttowhichtheycaninfluencedecisionsoftheNHSCommissioningBoard.Rolesandresponsibilitiesofallnewbodiesneedtobedefinedmuchmoreclearly.

n Althoughsomeshadowboardsaretakinganimaginativeapproachtoengagingwithstakeholders,theexclusionofproviderscouldundermineintegratedworking.Localauthoritiesshouldlookafreshatwaysofworkingwithlocalpartnersratherthanre-badgingpreviouspartnershiparrangements.

n Ourviewisthatthecreationofhealthandwellbeingboardswillnotautomaticallyremovemanyofthebarrierstoeffectivejoined-upcare.Forboardstosucceed,astrongernationalframeworkforintegratedcareisneededwithasingleoutcomesframeworktopromotejointaccountability.

n Thediscretiongiventolocalauthoritiesinsettingupboardsmeansthatdifferentapproacheswillemerge,andsomewillbemoreeffectivethanothers.Capturingandsharinglessonslearnedfromshadowboardswillbevitaltoavoidsimplyaddingafurtherlayerofunacceptablevariationtothesystem.

n Ourfindingssuggestthatthebiggestchallengefacingthenewboardsiswhethertheycandeliverstrong,credibleandsharedleadershipacrosslocalorganisationalboundaries.Unprecedentedfinancialpressures,risingdemand,andcomplexorganisationalchangewillseverelytesttheirpoliticalleadership.Boardmembersneedtimeandresourcestodeveloptheirskillsandrelationshipswithotherstakeholders.


Health and wellbeing boards

IntroductionInitsWhitePaper,Equity and Excellence: Liberating the NHS (DepartmentofHealth2010a),thegovernmentsetoutitsintentiontostrengthentheroleoflocalgovernmentinlocalhealthservices.Statutoryhealthandwellbeingboardswouldbeestablishedacrossthecountrytoencouragelocalauthoritiestotakeamorestrategicapproachtoprovidingintegratedhealthandlocalgovernmentservices. TheboardswillbringtogetherthoseinvolvedacrosstheNHS,publichealth,adultsocialcareandchildren’sservices,aswellaselectedrepresentativesandrepresentativesfromHealthWatch,tojointlyplanhowtheycanbestmeetlocalhealthandsocialcareneeds.

Theseproposalsweresetoutinmoredetailintheconsultationpaper,Liberating the NHS: Local democratic legitimacy in health (DepartmentofHealth2010b), andfurtheramendmentsweremadeasaresultofthelisteningexerciseandtherecommendationsmadebytheNHSFutureForum(2011).

TheproposaltoestablishhealthandwellbeingboardshasemergedunscathedfromthewidercontroversiessurroundingtheHealthandSocialCareBill,andhasbeenalmostuniversallywelcomed.Astrongeremphasisontheneedforintegrationasaprincipleofthereformshasseenthepowersanddutiesoftheproposedboardsenhanced.InthewordsofthePrimeMinister,DavidCameron:

… health and wellbeing boards will help this [integration] further. They will bring together everyone from NHS commissioning groups to adult social care specialists, children’s trusts and public health professionals… to design local strategies for improving health and social care integration. Integration is really important for our vision of the NHS.

(Cameron2011)

Thevisionofjoined-up,well-co-ordinatedandjointlyplannedservicesisnotnew,andthisisnotthefirsttimethatnewbodieshavebeencreatedtohelpachievethatvision.Pastefforts–includingjointconsultativecommitteesandjointcareplanningteams,and,morerecently,localstrategicpartnerships–haveachievedmixedresults.AlthoughinmostplaceslocalauthoritiesandNHSpartnershaveapartnershipboardofonekindoranother,thetrackrecordonintegratinghealthandsocialcarehasbeenpatchy.

HealthandwellbeingboardsaretheonlycomponentofthenewandincreasinglycomplexarchitectureofthereformedNHSthatwouldbringtogetherdifferentorganisationsandintereststopromotelocalcollaborationandintegration.Facedwithcomplexorganisationalchange,unprecedentedfinancialpressuresandrisingdemandforservices,willtheboardsbeabletofulfiltheseexpectationsandachievegreatersuccessthanpreviousbodies?

Background to this report

ThisreportformspartofawiderprogrammeofworkbeingcarriedoutbyTheKing’sFundonhealthandwellbeingboards.Theprogrammehassupportedseverallocalauthoritiesandtheirhealthpartnerstodeveloptheirshadowboards.InJuly2011,weheldasummitattendedbymorethan100delegatesfromlocalgovernment,theNHSandthethirdsector.

Aspartoftheprogramme,inlate2011,weconductedasurveyof50localauthorityareascoveringallregionsofEnglandtofindouthowtheyandtheirhealthpartnersareimplementingthenewboards.TelephoneinterviewswereconductedinSeptemberandOctober2011withleadofficersidentifiedbylocalauthoritiesthemselves(thefullmethodologyisdescribedinAppendix1).Thisreportsetsoutthefindingsfromthat



survey(seeAppendix2),andpresentscasestudiesbasedontheexperienceoftwoearlyimplementers,LambethandSurrey–eachfacingverydifferentcircumstances.Wealsoexplorethepolicycontextinwhichthenewhealthandwellbeingboardswilloperateanddescribethreepossiblescenariosthatcouldemerge.

Thepurposeofourresearchforthisreportwas:

n togaininsightsintohowlocalauthoritiesandtheirhealthpartnersareimplementinghealthandwellbeingboardsinthecontextofthegovernment’sNHSreforms,itsvisionforadultsocialcare,andtheLocalismBill

n tocapturetheoverallapproachofasampleofEnglishcouncilsinestablishingthesenewarrangements,supportedbyamoredetailedexaminationoftheexperienceoftwoearlyimplementersitesreceivingsupportfromTheKing’sFund

n toidentifythelessonsthatcouldbeappliedtotheroll-outofhealthandwellbeingboards,theissuesthatlocalauthoritiesandtheirhealthpartnersneedtoaddressinthenextstageoftheboards’development,andtheimplicationsforpolicy.

Beforepresentingourfindings,wesetoutthepolicycontextarisingfromthegovernment’splansforNHSreform,theproposedrole,functionandmembershipofthenewboards,andwhatcanbelearnedfrompreviouseffortstoachievebetterpartnershipworkingbetweenlocalgovernmentandtheNHS.

The policy contextThegovernmenthasstatedthatoneaimoftheNHSreformsistoimprovedemocraticlegitimacybyenhancingtheroleoflocalauthoritiesintheplanningandoversightoflocalhealthservices.Thiswouldseelocalauthoritieshavingfourmainareasofresponsibility:

n leadingthedevelopmentofjointstrategicneedsassessmentsandlocalhealthandwellbeingstrategiessothatthereisanoverallstrategicframeworkforcommissioning

n supportinglocalvoice,includingcommissioningthelocalHealthWatchandpromotingpatientchoice

n promotingjoined-upcommissioningoflocalNHSservices,socialcareandhealthimprovement

n leadingonlocalhealthimprovementandpreventionactivity.

AlllocalauthoritiesareexpectedtohaveshadowboardsinplacefromApril2012and,subjecttolegislation,theyshouldbecomefullyoperationalfromApril2013.Therenaissanceoflocalgovernment’sroleinhealthservices,whichisimplicitinthecreationofthehealthandwellbeingboards,explainstherelativepopularityofthisaspectofthereforms.Morethan90percentoflocalauthorities(132)havesteppedforwardtobecomeearlyimplementersofthenewboards,showing,inthewordsoftheDepartmentofHealth,‘...the appetite in local government to take on the strengthened leadership role which is at the heart of the Government’s vision for health and care’(DepartmentofHealth2011c).However,theprospectofastrongerroleforlocalgovernmentmightalsoexacerbatelongstandingnervousnesswithintheNHSaboutlocalelectedpoliticiansbecomingmoreinvolvedintherunningoflocalhealthservices(NHSConfederation2011a).

ItissignificantthatthisisthefirstmajorreorganisationoftheNHSthatwillseelocalgovernmenttakeonnewfunctionsfromtheNHS.Thisrunscountertothetrendduringtwopreviousreorganisations,in1948and1974,whenlocalgovernmentlostresponsibilitiesforhospitals,communityhealthservicesandpublichealth.Thecurrentreformsreflecttheimportanceofawiderangeoflocalauthorityfunctionsthatimpactuponthehealthandwellbeingoflocalpopulationssuchassocialcare,education,leisure,transport,environmentalhealthandcommunitysafety.Italsochimeswiththecoalition



government’slocalistphilosophyofmovingawayfromtop-down‘onesizefitsall’solutionstoservicesthataredesignedlocallyandreflectlocalpeople’sneeds.

What is the role of the boards?

Themainfunctionsofthehealthandwellbeingboardsare:

n toassesstheneedsoftheirlocalpopulationthroughthejointstrategicneedsassessmentprocess

n toproducealocalhealthandwellbeingstrategyastheoverarchingframeworkwithinwhichcommissioningplansaredevelopedforhealthservices,socialcare,publichealthandotherserviceswhichtheboardagreesarerelevant

n topromotegreaterintegrationandpartnership,includingjointcommissioning,integratedprovision,andpooledbudgetswhereappropriate.

TheNHSOperatingFrameworkfor2012/13describeshealthandwellbeingboardsascentraltothenewsystemandstatesthattheywill‘providelocalsystemsleadershipacrosshealth,socialcareandpublichealth’(DepartmentofHealth2011d).ThesecondreportoftheNHSFutureForumdeclaresthat‘health and wellbeing boards must become the crucible of health and social care integration’ (NHSFutureForum2012)andthegovernment’sresponseconfirmsthatitsees‘health and wellbeing boards acting as one of the engines of integration in the reformed system with the ambition of improving local care’(DepartmentofHealth2012).

FollowingtherecommendationsmadebytheNHSFutureForum,theroleoftheboardshasbeenstrengthenedinresponsetoconcernsthattheymaynothavesufficientpowerstofulfillthefunctionsrequiredofthem.Thekeyareasthatwerestrengthenedareasfollows.

n ThereisastrongerexpectationforNHScommissioningplanstofollowthelocalhealthandwellbeingstrategy;boardswillbeabletorefercommissioningplansbacktoclinicalcommissioninggroupsortheNHSCommissioningBoardiftheyfeeltheydonotsufficientlytakeaccountofthelocalhealthandwellbeingstrategy.

n BoardsmustbeconsultedbytheNHSCommissioningBoardonhowclinicalcommissioninggroupshavecontributedtothedeliveryofthelocalhealthandwellbeingstrategy.

n Theengagementofhealthandwellbeingboardsinclinicalcommissioningwillbestronger–‘not a formal, one-off exercise but rather an ongoing dialogue with a view to producing a commissioning plan that is the result of a joint effort’(DepartmentofHealth2011c).

n TheboardswillprovideadvicetotheNHSCommissioningBoardovertheauthorisationofclinicalcommissioninggroups.

n Ithasbeenclarifiedthattheboundariesofclinicalcommissioninggroupswouldnormallybeexpectedtobecoterminous(ie,followlocalauthorityboundaries)unlessthereareexceptionalreasonswhythisisnotappropriate.

Board membership

Thehealthandwellbeingboardistobeacommitteeofupper-tierlocalauthorities.TheHealthandSocialCareBill(HouseofLordsBill2010–12)setsoutthecoremembershiprequiredofeachboard,butbeyondthis,membershipwillbeatthediscretionofthelocalauthority.



Thecoremembershipshouldconsistof:

n atleastonenominatedcouncillorofthelocalauthority

n thedirectorofadultsocialservicesforthelocalauthority

n thedirectorofchildren’sservicesforthelocalauthority

n thedirectorofpublichealthforthelocalauthority

n arepresentativeofthelocalHealthWatchorganisation

n arepresentativeofeachrelevantcommissioninggroup

n suchotherpersons,orrepresentativesofsuchotherpersons,asthelocalauthoritydeemsappropriate.

Thebroadremitofhealthandwellbeingboardsmeanstheywillneedtoengagewithawiderangeofstakeholdersaswellaslocalpeopleandcommunities.Thiscannotbedonethroughformalboardstructuresalone;theywillneedtofindmoreimaginativewaysofengagingwithstakeholders,includingusingsocialmedia.TheBillsetsoutlegislativedutiesforlocalclinicalcommissioninggroupsandtheNHSCommissioningBoardtohaveregardtotheworkofthehealthandwellbeingboardwhenexercisingtheirfunctions.Therearealsobroaderrequirementsandexpectationsofvariouslocalandnationalpartnerstoco-operatetoensurethatthehealthandwellbeingboardsareabletoachievetheirobjectives.Figure1,overleaf,setsoutthesekeyrelationships.



Consideringtherolesofthehealthandwellbeingboardinthecontextofthiswidermapofrelationships,itisclearthattheirprimarypurposeisnottodirectlymanagethecommissioningactivitiesofclinicalcommissioninggroupsorthelocalauthorityitself.Rather,itistoestablishastrategicframeworkwithinwhichresourcesfromacrossorganisationalboundariesareappliedtotheoutcomesidentifiedinthehealthandwellbeingstrategy.Thiswillbeachievedthroughusingskillsininfluencingandrelationship-buildingratherthanformalmanagerialcontroloraccountabilities(healthandwellbeingboardshavenopowerstosignoffthecommissioningplansofclinicalcommissioninggroups,forexample).Thisroleisdescribedmorefullyintheoperatingprinciplesdevelopedbynationalorganisationsforestablishingeffectiveboards(NHSConfederation2011b).

Back to the future?

Healthandwellbeingboardshavebeenhailedasanewandinnovativevehicleforpartnerships,withtheunusualfeatureoflocalelectedmemberssittingalongsideseniorofficersofthelocalauthorityandlocalNHS.Thehistoryofjointworkingdoes,however,offersomeinterestingprecedents.The1974NHSreorganisationplacedanewstatutorydutyonhealthandlocalauthoritiestoco-operatewitheachotherandrequiredthemto

Figure 1 Some of the national, subnational and local bodies with which health and wellbeing boards will need to develop relationships

Source: Local Government Association (2011).HWB: health and wellbeing boards; CCG: clinical commissioning groups; LSP: local strategic partnership

NHSCommissioningBoard

Departmentof Health

Public HealthEngland

Monitor

NICE

NATIONAL

HealthWatchEngland

Care QualityCommission

Public HealthEngland

MonitorCare QualityCommission

SUBNATIONAL

Jointscrutiny

Possible HWB federations

Clinicalnetworks

Clinicalsenates

NHSCB North-South-Midlands-London

Neighbourhoods Voluntary andcommunity groups

COMMUNITIES

LOCAL

CarersService users

The publicPatients

Socialenterprises

Districts

Councildepartments

Children andyoung people

Health and socialcare professionals

HEALTH AND CARE PROVIDERSPARTNERSHIPS

EnterprisesCrime and safety Private sector

Safeguarding

Environment

LSPNHS providertrusts

Voluntary andcommunity providers

HWBCouncil CCGs

HealthWatch



establishjointconsultativecommitteestofacilitateco-operationandjointplanning.Thesebeganasadvisoryratherthanexecutivedecision-makingbodies,withechoesoftoday’sconcernsthathealthandwellbeingboardsmaynothavesufficientdecision-makingpowers.Itwashopedthattheinvolvementofseniorelectedmemberswouldsignaltheinfluenceandimportanceofthesenewjointcommittees.

Theinitialimpactofthenewarrangementsunderthe1974reorganisationwaslimited,withthethenSecretaryofState(thelateBarbaraCastle)referringtothe‘somewhat patchy progress... being made in getting the Joint Consultative Committees and local authorities fully operational’.Shewenton‘to plead with (health authorities) to regard co-operation with local authorities as a high priority, for without it the concept of community care to which we are all committed will become another empty cliché’(CastleinWistowandFuller(1983)).

Jointconsultativecommitteeswerelaterstrengthenedthroughtheadditionofjointcareplanningteamsandjointfinance–thelatteranearlyattemptto‘nudge’partnerstowardscollaborationbymakingNHSmoneyavailableforjointlyagreedprojects,managedeitherbythelocalauthorityorthevoluntarysector,thatwouldalsobenefittheNHS.However,thesumsinvolvedweresmallandthemainimpactappearedtobeoffsettinglocalauthoritybudgetcutsratherthanpioneeringnewformsofjointinvestment(WebbandWistow1987).Thehighhopesoftheearly1970swerequicklydashedbyeconomiccrisisandtheresultingpublicspendingcuts.Therearepotentialparallelshere,asnascenthealthandwellbeingboardsarebeginningtheirfunctionsinasimilarlyifnotmorehostilefinancialclimate.

Jointconsultativecommitteearrangementsweredisplacedbyvariouskindsoflocalpartnershipboarddesignedtoachievestrategicco-ordination,thoughevidenceoftheireffectivenessislimited.TheLabourgovernmentthatprecededthecoalitiongovernmentpromotedlocalstrategicpartnerships,whichsoughttocreatetheconditionsthatincentivisedpriority-focused,cost-effectivejointworkingbetweenlocalpublicserviceorganisations,aswellastheprivate,business,communityandvoluntarysectors(SullivanandTurner2011).

TheLocalGovernmentandPublicInvolvementinHealthAct2007reinforcedtheroleoflocalstrategicpartnershipsbutdidnotmakethemcompulsory.However,theActintroducedpublicserviceagreementsandthenstatutorylocalareaagreementswithadutyonnamedpartners–includingNHSbodiesandlocalauthorities–toco-operatewiththelocalareaagreements.Resultsfromathree-year(multipart)nationalevaluation(2007–10)ontheeffectivenessoflocalareaagreementsandlocalstrategicpartnershipsindeliveringbetteroutputsandoutcomessuggestedthattheextentofcollaborativeinnovationandpartnershipworkinghadvariedacrosslocalauthorityareas,dependingonhowitwas‘understoodbylocalstakeholders,i.e.whetheritisperceivedtoexistasarelativelyautonomousentitydistinctfrompartnersandwithsomeagencyofitsown,orwhetheritisperceivedsimplyasareflectionoflocalpartnerinterests’(SullivanandTurner2011,p31).

Further,areviewofthesepartnershipscarriedoutbytheAuditCommission(2009)highlightedthefollowingfindings.

n Eachlocalstrategicpartnershiphasuniquefeatures,buttherestillareimportantlessonstolearnfromeachother.

n Theymaynotcontrollocalpublicservicesresources,buttheyshouldstillbeabletoinfluencepartners’mainstreamspendingandactivity.

n Thereisaneedtodevelopstrongculturestoachievesharedgoals.

n Inmulti-tierareas,therearegreaterchallengesforthesepartnershiparrangementsthanthoseinsingletiers.



n Despitethefactthattheyarevoluntary,unincorporatedassociations,theymustrecognisetheirstrategic,executiveandoperationalroles.

n Asthesearrangementsarevoluntary,governmentdepartmentsshouldnotplacebureaucraticburdensorexpectationsonthem.

TheseconclusionsechothoseofanearlierassessmentbytheAuditCommissionthatalthoughthepotentialbenefitsofpartnershipworkingareconsiderable,theyareveryhardtorealiseinpractice.Partnershipworkingisextremelydifficult,expensiveandbesetbyobstacles,atbothlocalandnationallevels(AuditCommission1998).Areviewofthegovernanceofpartnershipsfoundthatthereisverylittlehardinformationabouttheimpactofpartnershipworking;thingscaneasilygowrong–athirdofthoseworkinginpartnershipsexperienceproblems,accordingtoauditors;leadership,decision-making,scrutinyandsystemsandprocessessuchasriskmanagementwereallunder-developedinpartnerships(AuditCommission2005).

ThechallengesofpartnershipshavebeenillustratedmorerecentlybyanevaluationofScotland’sCommunityHealthPartnerships(CHPs),establishedfrom2004asstatutorybodiestoimprovepeople’shealthandqualityoflifebyjoininguphealthandsocialcareservicesandmovingmoreservicesfromhospitalsintothecommunity.Evidenceofimprovementwaslimitedandpatchy,reflectingnumerousbarriersincludinghealthboardsandcouncilsseparatelymanagingresources,suchasbudgetsandstaff,andproblemsinsharinginformation(AuditScotland2011).

Muchofthisevidenceandexperienceisdirectlyrelevanttohealthandwellbeingboards,whicharelikelytofacesimilarchallenges.Whiletheywilldifferfrompastarrangementsinanumberofimportantways–includingthestatutoryrequirementforeverylocalauthorityareatohaveahealthandwellbeingboardandtoproduceaneffectivejointstrategicneedsassessmentandhealthandwellbeingstrategy–thenewboardswillhavetoadoptastrategicapproachtopromotingintegrationandachievingbetteroutcomesfortheirlocalpopulation.Theywillhavetodothisnotthroughexercisingmanagerialauthorityorcontrol,butthroughinfluencingandleadingacrossorganisationalandprofessionalboundaries.Theywillalsograpplewiththesamelogisticalchallengesaspreviouspartnershipbodies,butinthecontextofthemuchmorecomplexorganisationalarchitecturearisingfromtheNHSreforms,inwhichtherolesofclinicalcommissioninggroups,theNHSCommissioningBoardandlocalauthoritiesremainunclear.Inaddition,healthandwellbeingboardsbegintheirtaskinthefaceofevengreaterfinancialpressuresthanthosethathelpedtounderminetheearlyeffortsoftheirjointconsultativecommitteepredecessorsinthe1970sand1980s.

Giventhehistoryofpartnershipworkingandthecurrentfinancialclimate,howlikelyisitthatthenewboardswillsucceedinbringingtogetherthelocalNHS,publichealthandlocalgovernmentineffectiveanddynamicpartnershipsthatachievebetterhealthandwellbeingoutcomesfortheirlocalpopulation?Inthenextsection,weassesshowlocalauthoritieshavebeguntodevelopnewarrangementswiththeirpartners.Welookatthesize,compositionandwaysofworkingemergingfromtheshadowboards.Finally,weconsiderthefactorsthatarehelpingandhinderingtheireffectiveness.

Survey findingsExisting working relationships

MostlocalauthoritieshadbeguntodeveloptheirboardwithapositiveviewoftheircurrentworkingrelationshipwithlocalNHSpartners.Onascaleof1(poor)to6(good),84percentchoseascorebetween4and6(see Figure2opposite).Thismayberelatedtothefactthatmorethanfour-fifthshadsomeformofstrategichealthandcarepartnershipboardinplacepriortothereforms.Shirecountieswerelesslikelytohaveaboard.



Severalintervieweesmentionedahistoryofgoodlocalrelationshipsorrecentprogressinovercomingpastdifficultiesthathadledtoimprovedrelationships.Manywerealreadyplanningtointegratehealthandsocialcareandotherlocalserviceslikeleisure,culturalservicesandhousing,whichhaveadirectorindirectimpactonthehealthandwellbeingoflocalcommunities.Mostinterviewees(82percent)reportedthatthedirectorofpublichealthwasjointlyappointed,andthevastmajorityhadbeeninpostforatleastoneyear.

Figure 2 Local authority relationships with local NHS

Thesefindingssuggestagenerallyoptimisticandupbeatviewofrelationshipsandapositivestartingpointfordevelopingthesefurtherthroughhealthandwellbeingboards.Thishelpstoexplainwhylocalauthoritiesinoursamplehadmovedquicklytoestablishboards;allexcepttwoalreadyhadshadowarrangementsinplace(eventhoughthesedidnothavetobesetupuntilApril2012)and80percenthadalreadyheldtheirfirstmeeting.Theextenttowhichthesewererevampedversionsofpre-existingboardswasnotalwaysclear.Some(includingLambeth,oneofourcasestudies,onpage14)haddecidedfromtheoutsettorethinkhowtheywantedtoworkwithclinicalcommissioninggroupsasnewpartners,aimingtodevelopcompletelynewarrangements.

Only7ofthe50localauthorityareasincludedinthesurveywerenotpartofthenetworkofearlyimplementerssetupbytheDepartmentofHealthinMarch2011.

Size and composition of the shadow boards

Size

Ofthe48shadowboardsthathadalreadybeensetup,21hadupto12members,23hadbetween13and20members,and4hadmorethan20members.Unitaryauthoritiesweremorelikelytohavesmallerboards,shirecountiesandmetropolitanboroughslargerones(see Figure3overleaf).Thisseemstoreflectthelikelihoodthatshirecountyboardswillbeswelledbydistrictcouncilmembersandhaveseveralclinicalcommissioninggroups.Manymetropolitanboroughswillhavemoreclinicalcommissioninggroupsthanunitaryauthorities.

40 100600 8020

Shire county N=8

London borough N=11

Metropolitan district N=14

Unitary authority N=17

Percentage

Sample size: 50

12.5

18.2

14.3

6.3

50.0 37.5

18.2 36.4

42.9

9.1

35.7

56.3 37.5

7.1

18.2

Sample size: 50

Perc

enta

ge

Shire countyN=8

London boroughN=11

Metropolitan districtN=14

Unitary authorityN=17

0

20

40

60

1 2 3 4 5 6

poor working relationship

excellent workingrelationship



Figure 3 How many members are on the board?

Thesizeoftheboardisimportant,asthereareconcernsthattoomanypeoplearoundthetablewillreducetheeffectivenessofmeetingsandfuelconcernsthatthehealthandwellbeingboardswilljustbecome‘talkingshops’.Evidencefromprivatesectororganisationssuggeststhatbetter-performingcompanieshavefewerboardmembers,andthegeneralconsensusseemstobethatamembershipofbetween8and12islikelytoprovemosteffective(Eversheds2011;Imisonet al2011).Morethanhalfoftheboardsinoursurveyhadmoremembersthanthis.However,publicsectororganisationsarelikelytobelargerbecauseofthewiderrangeofintereststheyareexpectedtoinclude.Strivingtoachieveabalancebetweeninclusionofstakeholdersandboardeffectiveness,mostcouncilshaveavoidedverylargeboardsof20ormoremembers.

Onerespondentexplainedthat‘a tight core membership’fortheirboardhadbeenestablished,butthat‘a wide network which can stimulate and generate ideas’,involvingthethirdsectorandthepublicamongothers,hadbeenengagedandwasexpectedtoremaininvolvedintheboard’swork.Wewillreturntothislater(seepage12).Sixboardshadestablishedasmallerexecutiveorofficers’groupresponsiblefordrivingprogressoutsideofboardmeetings.

Mostboards(77percent)wereplanningtomeeteverysixtoeightweeks,with10percentplanningtomeetasoftenaseverymonth.Atonelevel,thismayreflectastrongcommitmenttogettheboardsupandrunning.Theremaybevalueinmeetingmoreoftenintheearlystagessothatnewworkingrelationshipscanbenurturedandmomentumgenerated.Butasboardsagreeprioritiesandworkprogrammes,itisdifficulttoseehowthisfrequencycanbemaintained–particularlyiftheywishtoengagewithabroadergroupofpartnersanddemonstrateprogressbeyondandbetweenboardmeetings.

25

36.4

30.8

68.75

<12 members 13–20 members 20+ members

12.5

18.2

7.762.5

45.5

61.5

31.25

N=23

Sample size: 48

Shire county London borough Metropolitan district Unitary authority

Perc

enta

geN=21

N=4



Composition

Thecomposition ofboards(asshowninFigure4below)largelyreflectstheprescribedcoremembershipsetoutintheHealthandSocialCareBill.Thelevelofengagementofmoststakeholders–intermsofattendanceandcontributiontomeetings–wasdescribedverypositively,andconfirmsthatlocalauthoritiesandclinicalcommissioninggroupsareforgingnewrelationships.Averyhighlevelofengagementascribedtoadultsocialcareisunsurprisinggiventhatpolicyresponsibilityforestablishingtheboardsrestswithinthisdirectorateinmostlocalauthorities.Butengagementofpublichealthisevenhigher,despiteconcernsaboutthetransferofpublichealthfunctionsintolocalgovernment.

Mostshadowboardshadnotgonebeyondthistoappoint‘such other persons, or representatives of such other persons, as the local authority thinks appropriate’,withtwosignificantexceptions.Thefirstisthatthevoluntaryandthirdsectorwasrepresentedonjustoverhalf(57percent)ofboards.Thesector’scontributiontocommunityhealthandwellbeingiswelldocumented;itrangesfromsupportingpatientandcitizenrepresentationandadvocacy,andknowledgeofcommunityneeds,tospecificexpertisegainedfromtheirserviceproviderrolethatwillbevaluableininformingthelocaljointstrategicneedsassessmentandhealthandwellbeingstrategy.However,thesheerrangeanddiversityoftheselocalgroupsposeschallengesforsecuringeffectivemembershipatboardlevel,andoffersoneexplanationforwhyasubstantialminorityofboardsinoursampledidnothavethirdsectorrepresentation.

TherewasasimilarthoughlessmarkeddividinglineintheinvolvementofNHSacuteproviders,whowererepresentedonaquarteroftheshadowboards.Here,theirinvolvementwasseenascrucialtopromotingintegrationacrossthelocalhealthandsocialcareeconomy.Somealsorecognisedthevalueofhavingasubstantiallocalemployerrepresentedontheboard.

Attitudestowardsprovidermembershiprevealdifferentviewsaboutthefundamentalpurposeofthehealthandwellbeingboards.Forthemajority,theprimaryfocusisoncommissioning,andproviderinvolvementwasseenasinappropriate,possiblyevenleadingtoconflictofinterests.Manyboardswereseekinginsteadtoengagewithprovidersoutsideofformalboardmeetings.

Figure 4 Who is represented on the board?

40 100600 8020

Public and patient involvement groups

Hospital trusts and secondary providers

Public health

Voluntary/third sector groups

Councillors

Social care

Clinical commissioning groups

District councils

Percentage

Sample size: 48

Yes NoAre the following represented on your board?



Beyond the board — engaging stakeholders

Thesedifferentemergingtrendsinthesizeandcompositionofboardsreflecttheextenttowhichtheyareinvolvinglocalstakeholdersmorewidelybeyondthemembershipthatisformallyrequired.Mostrespondentssawthisdevelopmentasanimportantwayofensuringbuy-intothenewsystemfromthewidercommunity.

Manylocalauthoritieshadheldinformalmeetingsandworkshopspriortotheformationofshadowboards;asmallnumberwerecontinuingtodosoeitherinplaceoftheshadowboardorbyalternatingpublicmeetingswithboardmeetings.Thesewereviewedasausefulwayofbringingallthepartiestogethertobuildrelationships,developandformalisemembership,andagreetheirremitandworkplans.Anumberofrespondentshighlightedtheimportanceofworkingcloselywithnewclinicalcommissioninggroups,andfourshadowboardshadorganisedmeetingsandeventswithclinicalcommissioninggroupmemberstocultivatethiscriticalrelationship.Asonerespondentexplained‘[We] started last year with a showcase of local government roles for the GPs, showing them that this is what we offer.’

Somelocalauthoritieshadorganisedlocaleventsandmeetingswithproviders,voluntaryorganisations,schoolsandotherrelevantcouncilservicessuchashousingandenvironmentalservicestoconsultwithandengagelocalgroups.Surrey,oneofourearlyimplementercasestudies(seepages15–16),hadworkedhardtoensurethattheir11districtcouncilswithresponsibilityforthesekeyfunctionscouldcontributetoanunderstandingofthedifferentneedsoftheirlocalpopulations.Lambeth,ourothercasestudy(seepage14),hadadoptedcitizenengagementasoneofitsfirstpriorities,seekingtoembedthisfromthebeginninginthewaytheirboardshouldwork.

Anumberofrespondentsmentionedthattheywouldbeholdingboardmeetingsalongsidepublicmeetingsandworkshopstoinvolveagreaternumberofpeopleorinterestgroupsfromwithinthecommunity.Thiswouldhelptheboardtounderstandtheneedsofdifferentlocalpopulationgroups.

Indesigningthenewarrangements,localauthoritieswerethinkingthroughhowexistingpartnershipbodiessuchasadultandchildren’ssafeguardingboards,children’strustsandwidergroupslikecommunitysafetypartnershipswouldbepositionedinrelationtotheshadowboard.Respondentsreportedwidevariations,withsomeusinghealthandwellbeingboardsastheoverarchingbodytowhichotherpartnershipsreported.

Who leads the board?

Atotalof25boardshadchosentheportfolioholderforhealth,adultsocialcareorchildren’sservicesastheirchair;17hadoptedfortheirlocalauthorityleaderordeputyleader,andintwocases,thelocalelectedmayor.Theseniorityoftheserolesreflectstheimportancethatlocalauthoritiesattachtotheboards,andahighlevelofpoliticalleadershipwasevidentinourtwocasestudies.Someboardshadmadeimaginativeandunusualchoices,suchasanindependentchairwithexperienceinhealthandsocialcare;onehadfilledthisrolewiththelocalsuperintendentcommanderofpolice,astheyfeltthispostholderhadaspecialinterestinthewellbeingofthecommunity.Intwocases,therolewassharedbetweenanelectedmemberandlocalprimarycaretrust(PCT)orNHStrustchair.Onlyoneboardwasledbythedirectorofpublichealth.

Twenty-fouroftheboardsweinterviewedhadnotyetassignedavice-chairastheywereintheveryearlystagesofdevelopment,butthereisatrendtowardsthelocalNHS–usuallythechairoftheclinicalcommissioninggroup–beingappointedtothisrole.Intwocases,thechairoftheLocalInvolvementNetwork(LINk)orHealthWatchhadbeenappointedvice-chair.ThesemodelsofsharedleadershipbetweenthelocalauthorityandthelocalNHS–especiallytheclinicalcommissioninggroups–augurwellfortheemergenceofmaturelocalpartnershipsthroughthenewboards.



Early issues and challenges

Alltheshadowboardssurveyedfacedsimilarchallengesinestablishinganentirelynewpartnershipbodywithahighdegreeofflexibilityanddiscretion.Intheabsenceofprescriptiveguidancefromcentralgovernment,localauthoritiesneededtofindotherwaysofidentifyinggoodpracticeandtochecktheirprogressagainstsomekindofexternalbenchmark.Theywantedtolearnfromotherlocalauthoritiesandshareknowledge–forexample,throughtheearlyimplementersnetwork.Othermethodsmentionedbyrespondentsincludedformingregionalpartnershipsandmeetingwithneighbouringlocalauthorities.

Anumberofrespondentsmentionedemployingorseekingtouseexternalorganisationsandfacilitatorstosupporttheformationoftheirboards.Thesevariedwidely;eachLondonboroughhadbeenallocated£15,000forboarddevelopmentwork,andLondoncouncilsandLondonNHStogetherhadcommissionedprogrammestosupportthedevelopmentoftheirboards.Inotherareas,boardshadapproachedotherorganisationsforsupport,includingTheKing’sFund,theLocalGovernmentAssociation,theAssociationforPublicServiceExcellence(APSE),andlocaluniversities.Obtainingthissupportwasseenasvitalto‘bridge the differences and lack of knowledge that [we] have about each other’andbalancetheculturegapbetweenthelocalauthorityandtheNHS.Thisfacilitationroleofteninvolvedmeetingwithindividualstakeholdersandrunningworkshops.Therewasonlyoneinstancewhereaninternalhealthandwellbeingboardco-ordinatorhadbeenrecruitedand,inthatcase,theirtaskswereverysimilartothoseundertakenbyexternalfacilitators.

Accesstosupportvarieswidelyindifferentpartsofthecountry,andthe‘newness’ofboardsasacross-organisationalvehiclewillcreateongoingneedsforleadershipandorganisationaldevelopmentthathaveyettobesystematicallyassessed.Thiswillbearealtestoftheabilityofsector-ledimprovementtomeettheseemergingdevelopmentneedsandavoidall152localauthoritiesreinventingthewheel.

Aswellasthesecommonchallenges,therewereadditionalissuesfacingdifferenttypesoflocalauthority.Aswehaveseen,shirecountiesexperiencegreaterorganisationalcomplexity,havingtofindwaysofengagingwithseveralclinicalcommissioninggroupsaswellasasecondtierofdistrictcouncils.Surrey,forexample,hasbeenworkingwithmorethan20statutorybodiesfromtheNHSandlocalgovernmentalone.Manyshirecountieshavedonewelltolimittheirboardmembershiptobelow20,butensuringengagementbeyondtheboardwilldemandsustainedattention.Theyalsocoverlargegeographicalareas,withurbanpopulationsaswellasdispersedruralcommunities.Thesearelikelytogeneratedifferentanddistinctivepatternsofneedthatwillbehardtocapturewithinasinglejointstrategicneedsassessmentandhealthandwellbeingstrategy.

Incontrast,metropolitanboroughs,unitarycouncilsandLondonmetropolitandistrictshaveamuchlesscomplexorganisationalarchitecture,withfewerorganisations.Theexpectationthatclinicalcommissioninggroupsshouldbecoterminouswithhealthandwellbeingboards(thatis,coverthesamegeographicalboundaries)shouldstrengthenpartnershipworking.Clearlydefinedandsharedgeographicalareasallowformorestraightforwardmembership,reporting,andstakeholderinvolvement.

Oneareathathadyettobeaddressedwashowthenewboardswouldberesourcedandserviced.Localauthoritiesareexpectedtoestablishtheboardsasformalstatutorycommittees,butarenotreceivinganyadditionalresourcetodothis.Someofourrespondentshadbeenusingcouncildemocraticteamsasadministrativecapacityfortheboard,whileotherswereusingexistingprojectmanagementcapacity.Somehadidentifiedtheneedtospecifywhatcontributionsotherorganisationsshouldmake–especiallyclinicalcommissioninggroups,asprincipalpartners–tothecostsofoperatingtheboards.



Case study: Lambeth

LambethisadenselypopulatedanddiverseinnerLondonborough,withhighlevelsofdeprivation.Morethanathirdofits274,000populationarefromethnicminoritiesand150languagesarespoken.Overhalfofitsworkforceareinprofessionaljobsbutahighproportionofthepopulationareeconomicallyinactive.Despitecomplexhealthandsocialcareneeds,recentyearshaveseengoodprogressintermsofhigherlifeexpectancy,fewerteenagepregnancies,andsmokingcessation.RelationshipsbetweenthecouncilandtheNHShaveimprovedsubstantiallyandbotharekeentobuildontheseachievements.Theorganisationallandscapeisstraightforward,withonecoterminousclinicalcommissioninggroup.

Followinginitialdiscussionsbetweenthecouncilandtheprimarycaretrust(PCT),itwasagreedtoadoptaphasedapproachtodevelopingthehealthandwellbeingboard.Theprocessinvolvedidentifyingtheoutcomesthatpartnerswanttoachievethroughtheboard,ratherthanrushingtoestablishitsgovernance,membershipandwayofworking.TherewasclearagreementthattheboardofferedLambethanewopportunitytoachievemoreforitsresidents,andthatsimplycontinuingwith‘businessasusual’basedonitspreviouspartnershipboardwouldbeneithereffectivenorappropriate.

Aseriesofworkshopswereheldfromspring2011,attendedby25participantsfromawiderangeofstatutoryhealth,socialcareandlocalgovernmentorganisations,includingtheLocalInvolvementNetwork.TheengagementofGPsinparticular,aswellaslocalfoundationandacutetrustsandelectedmembersfromacrossthepoliticalspectrum,isadistinctivefeaturethathasbeenparticularlyencouraging.Newconversationswereabletotakeplaceforthefirsttimebetweenorganisationsandclinicaldisciplines,notablyGPs.TheactiveandcommittedinvolvementofprovidershasbeenadistinctivefeatureofLambeth’sapproach;itreflectsthepresenceofKing’sHealthPartners,anAcademicHealthSciencesCentre(AHSC)thatbringstogetherthreemajoracutefoundationtrustswithanannualspendof£2billion(comparedwiththecombinedNHSLambethandcouncilspendofjustover£1.6billion).

Theworkshopsfocusedonrevisingthejointstrategicneedsassessment,takingintoaccountthecurrentprioritiesandplansofexistingorganisations,andhowthehealthandwellbeingboardcouldaddvalue.Thishashelpedtheorganisationsinvolvedtounderstandeachother’sagendasandconcerns.Amappingofexistingspendshowedthatthetotalpublicresourcethatfallswithintheremitoftheboardismorethan£1billion,andthatitscoremissionwillbetoconsideritsoveralldeploymentandwhatoutcomeswillbeachievedintermsofthejointstrategicneedsassessmentandhealthandwellbeingstrategy.

Theboard’sroleisseenasstrategic,withnodirectinvolvementindetailedcommissioning.Thisunderstandinghashelpedtoframeinitialpriorities;workstreamshavebeenagreedonandworkhasbegunoncitizeninvolvement,publichealth,integratedcareandearlyintervention.

KeyfeaturesofLambeth’searlyexperience:

n Anevolutionaryapproach,emphasisingrelationship-buildingandthedevelopmentofagreedsharedoutcomesratherthanformalboardmeetings.

n PositiveengagementofGPsandapartnershipapproach.

n Directinvolvementofacuteproviders,recognisingtheirexpertiseininnovationandfinancialscaleinrelationtothehealthandcareeconomy.

n Astrongfocusoncitizenengagementandco-production,rootedinLambeth’s‘co-operativecouncil’approach.



Case study: Surrey

Thisisalargeandcomplexhealthandcaresystem,coveringapopulationof1.1million.Therearemorethan20statutoryorganisations,including11districtcouncils,and12nascentclinicalcommissioninggroups.Thecountyisservedbyfiveacutehospitals(basedatfivetrusts,threeofwhichhavefoundationstatus),twomajorcommunityproviders(onesocialenterprise),acounty-widementalhealthtrust,and12GPcommissioningconsortia(10ofwhicharepathfinders).ItsgeographicallocationmeansthatsignificantuseismadeofLondonhospitals.Althoughthepopulationisrelativelyprosperousandhealthy,therearesubstantialinequalitiesintermsofsocialclassandethnicity,andbetweendifferentpartsofthecounty.Particularissuesofconcernarelifestyle-relatedillnesssuchasalcoholmisuse,smokingratesandchildhoodobesity.Theuseofresidentialcareisabovethenationalaverageandreflectstheageingpopulation.

RelationshipsbetweenthecouncilandNHSpartnershadimprovedsignificantlyinrecentyears.Buildingonthis,stakeholdersfromacrossthecountywerebroughttogetherinthreedevelopmentworkshopsinspring2011todevelopasharedvisionforthenewhealthandwellbeingboard.Thestartingpointwasastrongfocusonoutcomes,seekingstakeholderviewsonthreequestions:whatarethetopthreehealthandwellbeingprioritiesforlocalpeople?;whatneedstobedonetoaddressthem?;andwhatneedstobecommissioneddifferentlytoachievethoseoutcomes?

Workshopsinvolvedatleast60peopledrawnfromacrosslocalgovernmentandtheNHS,includingtheprivateandvoluntarysectorsandacutehealthproviders.AchievingeffectiveengagementonthisscaleisaparticularchallengeforshirecountieslikeSurrey,wherethereisasecondtieroflocalgovernmentintheformofdistrictcouncils.TheattendanceofGPleadsfromtheclinicalcommissioninggroupsreflectedtheircommitmenttotheprocess.

Earlythemesincluded:ensuringclarityofpurpose(avoidingtherisksoftheboardaddingafurthercomplicationtoanalreadycomplexsystem);mappingexistingspendandservicesacrossthecounty;understandingtheoverallpicture(anddifferenceswithinthecounty);andbuildingstrongrelationships,bothwithintheboardandexternally.Effortsweremadetoensurethatboardarrangementsdovetailedwithotherexistingandvaluedpartnerships(eg,thechildren’strust,safeguardingboards,etc).

MappingworkthroughthejointstrategicneedsassessmenthadshownthatcombinedspendingacrosstheNHS,adultsocialcareandchildren’sservicesamountedtomorethan£2billion.Thinkingfocusedonwhatkindofarrangementswouldbestensurethatthisresourceisusedmosteffectively;theconstructof‘TheTaylorfamily’wasproposedtothinkabouthowtheseresourcescouldbenefitlocalresidents.

Aclearconsensusemergingfromtheworkshopswasthatthepurposeoftheboardistopromotetransformationalchange,recognisingtheneedforfundamentalchangesinwhatservicesarecommissionedandhowthisisdone,ratherthansimplytinkeringwithorrepackagingexistingarrangements.

Bythetimeofthefinalworkshop,thecountycouncilwasabletoarticulatesomeclearmodelsfortheboard.Theseincluded:onemainboardand11localboardsbasedondistrict/boroughboundaries(drawingonpreviousworkofthelocalstrategicpartnerships);andatwo-tiermodelwithasingleboardandfoursub-groupsbasedonthePCTresourcehubsortheclinicalcommissioninggroupclusterareas.Thesemodelsreflectedtheneedtoensuretheengagementofbothdistrictcouncilsandclinicalcommissioninggroups,madedifficultbythelackofcoterminousgeographicalboundaries.



Theshadowyear(fromApril2012toApril2013)isseenasanopportunityforexperimentation,andashadowboardhasbeensetupandhasalreadymettwice.Chairedbythecouncil’scabinetmemberforadultsocialcareandhealthandco-chairedbyaGPlead,ithasapproximately27members(17ofwhichareGPleads).Therewillbewiderengagementactivitywithotherkeystakeholderswhoarenotmembersoftheboard.Theboardisnowdevelopingitsworkprogramme,includingtimescalesforthejointstrategicneedsassessmentandhealthandwellbeingstrategyfor2012/13.

KeyfeaturesofSurrey’searlyexperience:

n achievingasingleboardinacomplexsystemwithmultipleorganisationsandtwotiersoflocalgovernmentwillbechallenging

n thelocalauthoritycantakealeadrolebutmustsecuretheconsentofexternalpartners

n theemergingroleoftheboardisstrategic,overseeingtransformationalchangeandaddingvaluebybringingtogethermultiplestakeholders

n moreworkneedstobedonetoengagethevoluntaryandthirdsector.

Prospects for success?

Respondentsweregenerallyveryupbeatabouttheirexpectationsofwhattheboardwouldachieveagainstfourobjectivesthatreflecttheircorefunctions:deliveringlocallyidentifiedpriorities,achievingcloserintegration,morepooledbudgets,andimprovedplanningofcarepathways(seeFigure5below).

Figure 5 How effective will the boards be?

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agreeSomewhat

agreeNeither agreeor disagree

Somewhat disagree

Completely disagree

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Deliver on the identified priorities

Help achieve closer integration of services between local authority and NHS

Help to improve co-ordinated care pathway planning

Lead to increased pooling of commissioning budgets

Perc

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Weaskedrespondentswhatwouldbedifferentaboutthenewboardscomparedwithpreviousjointworkingarrangements.Theycited:

n greaterinvolvement/engagementofGPsinthehealthandwellbeingboards

n bettergovernanceandaccountabilitybecauseofthestatusoftheboardasacommitteeofthelocalauthority

n greaterabilitytosetthestrategicdirectionforhealthandwellbeinginthearea(includingbeingviewedasthelocalstrategicsystemleaderforhealth)

n awider,morepreventivefocus,consideringbothhealthand wellbeing(facilitatedbythemovementofpublichealthintothelocalauthority,andmoreeffectiveuseofjointstrategicneedsassessmenttohaveaclearerpictureoflocalneeds)

n achievinggreaterpartnershipworkingbetweenorganisations,particularlyacrossthebreadthofthelocalauthorityandthelocalNHS(thatis,greaterintegration)

n theimportanceofmakingtheboardastatutoryrequirement(unlikethelocalstrategicpartnerships)withgreaterinfluence–andsomeseeingitashavingexecutivedecision-makingpowers

n astrategicfocusoncommissioning,affectingbothmembershipoftheboardandthenatureofthelocalhealthandwellbeingstrategy.

Respondentswereaskedanopenquestiontonameuptothreefactorsthatwouldbemostsignificantinhelpinghealthandwellbeingboardsachievetheirobjectives.Theanswerswerethengroupedintothemesbytheresearchteam.ThekeythemesidentifiedaresetoutinFigure6below.

Figure 6 What factors will help boards to achieve their objectives?

10 25150 205

Strong working relationships

High level of commitment to health and wellbeing board

Commitment to integration

Agreement on priorities

High level of local control/flexibility

Productive joint strategic needs assessment and health and wellbeing board strategy

Trust between board members

The economic downturn

Clarity of purpose

Commitment from primary care

Additional financial resources

Greater patient and public involvement

Flexibility with funding

Success of clinical commissioning groups once formed

Number of responses



Themostfrequentlymentionedfactorwasstrongworkingrelationships.Thisincludedhavingfrankandfulldiscussionsbetweenboardmembers,agenuinewillingnesstoworkwithoneanother,andacommitmenttobuildingonpositiverelationshipsthatalreadyexistacrossorganisations.Itwasalsofeltthatahighlevelofcommitmenttoworkingontheboard,andtheabilitytoagreeonpriorities,werecriticalelementsforsuccess.Thesebothlinktotheneedforstrongworkingrelationships,andsuggestthateffectiveleadershipandmanagementqualitieswillbeessentialfortheboardstoworkeffectively.Commitmenttointegrationwasalsoseenasakeytosuccess,particularlythroughcloseralignmentandsharingofresources.

Interestingly,somerespondentsviewedtheeconomicdownturnasanopportunityratherthanaconstraint,inthatresourcepressureswouldencourageorganisationstothinkof‘newwaysofdoingthings’betweenthemselves,inpartnershipasopposedtoinsilos.Butsomerespondentssuggestedthatadditionalresourceswouldbeneededtosupportandservicetheworkoftheboardsiftheyaretodeliverwhatisrequiredofthem.

Turningtothefactorsthathinderboardeffectiveness,themostfrequentlycitedissuewasbudgetconstraints.ThefinancialchallengesfacingtheNHSandlocalgovernmentcreateanumberofrisks:thatorganisationswilltrytomanagethesepressuresbyretreatingintosilosinsteadoffullyembracingtheopportunitytoalignplansandresources;thattheywillnotsufficientlyprioritiseinvestmentinpreventionandwellbeingservices;orthattheywillnotreceivesufficientresourcesinthetransferofpublichealthresponsibilitiestotacklehealthinequalitiesandthewidercausesofillhealth.This,inturn,willweakentheircommitmenttopartnershipworking,therebyundermining‘sign-up’andcommitmenttotheboard(seeFigure7below).

Figure 7 What factors will hinder boards in achieving their objectives?

Lackofclarityaboutthescopeandpurposeoftheboardswasalsoasignificantconcern,especiallyattheinterfacewithotherNHSorganisations,intermsofhowtheirrespectiverolesandresponsibilitieswouldfittogether.

10 25150 205

Budget contraints

Not full sign-up

Lack of clarity

Siloed thinking

Continued structural change

Not working well together

High level of national control

High level of uncertainty

Too many priorities

Lack of leaderships

Delays

Too many processes

Number of responses



Thereorganisationofstructuresandchangesinkeypersonnelwereseenasimpedingthedevelopmentofstrongworkingrelationships.Structuralchangewasfrequentlymentionedasafactorthatwouldhindertheeffectivenessofthenewboards.Manyrespondentsfearedthatthecontinuedchangesatbothlocalandnationallevelswouldcreatefatigueandconfusionwithintheirlocalsystem,andthiswouldunderminerelationship-buildingandtheabilitytoreachlocalagreements.

Althoughthegovernment’sapproachtotheboardsisrelativelynon-prescriptive,somerespondentssawahighlevelofnationalcontrolasapotentialhindrance,andwereconcernedthatnational‘interference’wouldinhibitboardsfromworkingonwhatreallymatterstotheirlocalpopulations.

The joint strategic needs assessment and local health and wellbeing strategy

Acorefunctionofthenewboardsistodeveloptheirjointstrategicneedsassessmentandusethistoagreealocalhealthandwellbeingstrategy.Weaskedrespondentstoassesstheusefulnessoftheirexistingjointstrategicneedsassessment.Most(78percent)rateditonthehigherendofthescale(seeFigure8below),butintendedtodevelopitfurther.Somedescribeditastoomuchlikea‘shoppinglist’andsaidthatitneededtobemorefocused.

Themainideasforimprovingthejointstrategicneedsassessmentweretomakeitmorecomprehensivebywideningittoincludeotherareaslikehousing,employmentandculture.Manywantedtomakeitamoreuser-friendly,succinctandregularlyupdatedweb-baseddocumentthatwouldbemorehelpfultocommissioners,andsohavegreaterinfluenceontheirdecisions.Oneideawastomakethedocumentrelevanttothelocalpopulationbymappingtheneedsofpeopleatdifferentlevels(bypostcode,inwards,inprimarycare,etc);anotherwastodevelopgreaterownershipofthejointstrategicneedsassessmentthroughstrongerpublicandpatientinvolvement.

Thereisacleardesiretodevelopexistingjointstrategicneedsassessmentssothattheybringtogetherallrelevantinformationaboutlocalpopulationneedsandbecomeastrongerframeworkforintegratingsocialcare,publichealthandthelocalNHSinresponsetothoseneeds.DraftguidancefromtheDepartmentofHealthonjointstrategicneedsassessmentsandhealthandwellbeingstrategiesshouldhelpthenewboardstakeforwardtheseideas(DepartmentofHealth2012b).

Figure 8 How useful is your current joint strategic needs assessment?

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not useful very useful

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Anothercorefunctionofthenewboardsistoproducealocallyagreedhealthandwellbeingstrategythatactsastheframeworkinwhichlocalservicesarecommissioned.Howimportantwillthesestrategiesactuallybeininfluencinglocalcommissioningdecisions?Mostrespondentsthoughttheirstrategywouldbeveryinfluentialinrelationtothedecisionsofclinicalcommissioninggroups,butnotthoseoftheNHSCommissioningBoard,whererespondentswereeithernegativeorunsure.ThismirrorstheconcernsdescribedearlierabouttherelationshipbetweenhealthandwellbeingboardsandtheNHSCommissioningBoard.Thisisverysignificant,becausetheNHSCommissioningBoardwillberesponsibleforcommissioningalllocalprimarycare,dentistryandpharmacyservicesaswellasspecialisedservices–comprisingasmuchas£20 billionofthetotalNHSbudget.Ifthenewboardsaretopromotethestrategicco-ordinationofalllocalservicesrelevanttohealthandwellbeing,theywillneedtoinfluenceallcommissioningactivityaffectingtheirlocalpopulation–includingtheNHSCommissioningBoard.

Measuring success

Manyboardshadjustbeguntoconsiderhowtheywouldassesstheirimpactandsuccess.Morethanhalfwereplanningtomeasureboardperformanceagainstthedeliveryofstatedobjectivesreflectedinworkprogrammes,jointstrategicneedsassessments,andthejointhealthandwellbeingstrategy.Otherrespondentsmentionedevaluatingboardperformanceinternallyorexternallybyaskinglocalclinicalcommissioninggroupsorthepublictobeinvolvedintheprocess;andalsomonitoringattendanceatmeetings.Thelocalauthority’soversightandscrutinycommitteewasalsoseenashavingaroleinregularlyreviewingtheactionsandperformanceoftheboard.

Clarityaroundtheneedtouseprocessmeasurestoassessboardperformancecontrastedwithuncertaintyoverrespondents’aspirationstomeasuretheirsuccessindeliveringimprovedoutcomes.Aquarterofrespondentsplannedtoevaluatetheirperformanceagainstspecificoutcomes,althoughthesewereyettobefullydefined.Examplesofmeasuresbeingconsideredwerehealthinequalities,emergencyadmissionstohospital,accidentandemergency(A&E)waitingtimes,admissionsofover-75s,andpatient/usersatisfaction.

OthersplannedtousetheforthcomingNHS,publichealthandsocialcareoutcomesframeworkstodeveloptheirownsetofoutcomeindicatorsalignedacrossthethreeframeworks.Asmallnumberintendedtouseimprovementsintheintegrationofservicesasameasureoftheireffectiveness.

Severalrespondentssawthedevelopmentofsuccessfulrelationshipsbetweenthepartnersontheboardasatangiblewayofestablishingwhethertheboardwasworkingeffectively.The‘personaldynamics’oftheboardnotonlyreferredtoreachingagreementsbutreachingaleveloffamiliaritywheremembersfeltsecureenoughtoopenlydisagree.Asonerespondentsaid:‘In the past [we’ve had] no public disagreements. I would like one member to feel able to openly disagree with another in a meeting.’

Morethanathirdofboardshadnotyetdiscussedhowtheyplannedtoassesstheirsuccessorimpact.Asonerespondentexplained,theydid‘...not want to nail [our] colours to the mast too quickly. [It] will be linked to what a health and wellbeing board will need to do.’

Where next for health and wellbeing boards?MostlocalauthoritiesinoursamplehavegotofftoaflyingstartindevelopingthenewarrangementsbymovingquicklytoestablishshadowboardsaheadoftherequireddateofApril2012.Newrelationshipsarebeingforgedwithclinicalcommissioninggroups



andthereisahighlevelofengagementwithpublichealthcolleagues.Thefactthatmostboardsarebeingchairedbyseniorelectedmembers–insomecases,theleaderofthecouncilandelectedmayor–signifiestheimportancethatlocalauthoritiesareassigningtothenewbodies.Mostboardsareveryoptimisticabouttheirprospectsforsuccessinpromotingintegration,increasingjointcommissioning,anddeliveringlocallyagreedpriorities.Wefoundmanyexamplesofinnovationandcreativethinking.

Innovation – local examples

Manyplaceswerepursuingunusualandimaginativeideas.

n Oneboardfromametropolitandistrictappointedanindependentchair.ThispersonhadabackgroundinhealthandsocialcarebutwasnotemployedbythelocalauthorityorlocalNHS.Theirboardmeetingsweretakingplaceinaneutralsettingtohelpmembersfocusontheneedsofthelocalpopulation,ratherthantheorganisationstheyrepresented.

n Oneboardinaunitaryauthorityappointedthesuperintendentcommanderofpoliceasthechair.Thispersonwasverymuchinvolvedwiththecommunityandwaskeenontakingpartinintegratinghealthandsocialcarewithinthelocality.

n Manyoftheleadsinterviewedmentionedthattheirjointstrategicneedsassessmentinthefuturewouldhavemuchmoreofafocusonforecastingandmarketanalysis,notsimplyepidemiologicalaccountsofthepopulation.

n OneLondonboardwasplanninga‘Dragons’Den’-styleeventtoidentifyandchampionlocalinnovationsintacklinghealthinequalities.

n Oneshirecountywaspursuinganovelmethodofengagingcommunitiesindevelopingtheirjointstrategicneedsassessmentbysendingoutquestionnairestothecommunitiesinthedifferentdistrictsandotherstakeholders,askingthemwhathealthandwellbeingneedsshouldbeaddressed.Theresultswouldbefedintosevenworkshopsandanelectronicvotingsystemusedtoidentifythetop10priorities.

Working in a context of unprecedented challenges

TherehasrarelybeensuchstrongsupportforcloserrelationshipsbetweenNHSandlocalgovernmentandtheintegrationofservices.Expectationsofwhathealthandwellbeingboardscanachievearehigh,butthechallengingcircumstancesinwhichtheybegintheirworkareunprecedented.Thisraisessomefundamentalquestionsaboutwhatthenewboardscanrealisticallyachieve.

Overthenextdecadeandbeyond,theNHS,socialcareandrelatedservicesfacetheenormouschallengeofrespondingtotheneedsofincreasingnumbersofpeoplewithlong-termconditionsandanageingpopulation;thisatatimewhentheNHSleavesbehindthesubstantialreal-termfundingincreasesofthepasttofaceaproductivitygapof£20billion,andlocalgovernmentfacesanoverallreductionof26percentoverthenextfouryears.Bothtrendsrequirearadicalshiftfromamodelofcarebasedpredominantlyonacutehospitalstowardsamorepreventiveapproachthatpromotesself-careandismuchmorepersonalisedandco-ordinatedaroundtheneedsoftheindividual.Healthandwellbeingboardsmustplayacentralroleinthisshift,otherwisetheirimpactwillbeaspatchyaspreviouspartnershiparrangements.

Inmanyplaces,thiswillrequirechangesinhospitalprovision,involvingtheunpopularrationalisationorevenclosureofsomeservicesinordertoconcentratespecialistresourcesinfewersites.ArecentreviewbyTheKing’sFundofhowtoimprovehealthcareinLondonsetsoutanimportantroleforlocalauthoritieshelpingtoleadchangesthrough



healthandwellbeingboards(Applebyet al 2011).Butevenwherethereisacompellingcaseforchangeonthegroundsofclinicalsafetyoroutcomes,thelocalauthoritywillcomeunderpressuretoreflectlocalopinionandpreservevaluedlocalservices.Inthesecircumstances,thelocalhealthandwellbeingboardswillbeintheeyeofthestorm,andthecurrentwaveofgeneralisedgoodwillonwhichtheyhavebeenridingwillquicklydissipate.Atthispoint,thepoliticalleadershipoftheboardwillbetestedtothelimit.Ifboardscanrisetothechallengeandleadpublicopinioninsteadofmerelyfollowingit,thereiseveryprospecttheywillbreaknewgroundintransformingservicesandthelivesofpeoplewhousethoseservices–andavoidbecomingjustanothertalkingshopinthelonghistoryofpartnershipworking.

Oneofthecorefunctionsoftheboards–producingajointhealthandwellbeingstrategythatwillactasaframeworkwithinwhichalllocalservicesarecommissioned–willalsobeaformidabletest.Ifthesenewstrategiesaretobegenuinelyusefulandhavearealimpactoncommissioningdecisions,theywillneedtobemorethanawishlistofuncostedproposals.Instead,boardswillneedtoapplyrigorousprioritisationinassessingcompetingneedsanddemands,andaimtoreachagreementonthekeypriorities.Thiswouldbedauntingenoughforthemostmature,well-establishedpartnershipswithprovengovernancearrangements.Butthenewboardswillbeintheirinfancy,andoneoftheprincipalpartners–clinicalcommissioninggroups–willbeentirelynew,grapplingwiththeirowndevelopmentneeds.

Boardsarealsoemergingintoanewworldthatismorecomplexorganisationallythancurrentorpastarrangements,withresponsibilitiesdistributedacrossamultiplicityofclinicalcommissioninggroups,commissioningsupportorganisations,theNHSCommissioningBoard,clinicalsenatesandclinicalnetworks.PublichealthfunctionsaretobesplitbetweenlocalgovernmentandPublicHealthEngland.Aswehaveseen,thereisconsiderableuncertaintyabouttherespectiverolesandresponsibilitiesofdifferentbodies,especiallyduringthetransitionfromoldtonewarrangements,withtheresultingriskoforganisationalinstability.Healthandwellbeingboardswillbegrapplingwithemergingfaultlinesemergingfromthesedifferentpartsofthenewsystemaswellastraditionaldivisionsthatremainuntouchedbythereforms–forexample,themeans-testingofsocialcare,comparedwithNHScarethatisfreeatthepointofuse.

Thesechallengeswillbeplayedoutindifferentwaysindifferentplaces.Here,wepresentthreepossiblescenariosthatcouldemerge.Theyarenotmutuallyexclusivethough;elementsfromeachcouldbecombinedintoanynumberofpermutations.

Scenario 1 Towards system leadership

ThelocalauthoritydecidesearlyontoinitiatecontactwithlocalGPleadersandotherstakeholdersandholdsworkshopstodiscusshowtheycandevelopnewpartnershiparrangements.Theyagreetocompletelyrevisetheexistingjointstrategicneedsassessment.

ThelocalauthorityandLocalInvolvementNetwork(LINk)developapublicengagementstrategytotestoutemergingthemesandissues.Thisrevealswideagreementaboutsomeprioritiesbutsharpdisagreementsaboutothers(eg,changestoA&Efacilitiesneededforclinicalsafetyaswellfinancialreasons).Theboardagreestosetupanindependentcommissiontomakerecommendationsaboutthefutureshapeofhealthandcareservices,withaparticularfocusonhospitals.ItstermsofreferenceareagreedwiththeNHSCommissioningBoard.

Inthemeantime,theshadowboardagreessomeselectivebutambitiouspriorities,includingtacklingafast-risingelderlypopulation,escalatinglevelsofType2diabetes,andchildandadolescentmentalhealth.Thisbeginstohavesomeimpactonlocal



commissioningdecisionsandthereiseventualagreementtocompletelyredesignservicesforolderpeoplethroughasinglelocalcarerecordandtoformintegratedlocalityteams.

Pressuresonhealthandcarebudgetscontinuetogrow.Theboardcommissionsashort-lifetaskandfinishgrouptoreviewwhatcanbedonetomanagethesepressures.

Inthisscenario,theboard’sinfluenceandcredibilitywithlocalstakeholdersisgrowing,anddespiterelentlessfinancialpressures,itisbeginningtoofferleadershipacrossthewholesystem,promotinggreaterintegrationandaddressingtheneedformajorservicechange.

Scenario 2 Strategic co-ordination

Thelocalauthoritycoversamixedurbanandruralpopulation.Thereareseveralclinicalcommissioninggroupswhosepracticeboundariesoverlapwithadjacentlocalauthorities.IthastwoacuteNHStrustswhoderiveasubstantialpartoftheirincomefromout-of-areareferrals.Therearesubstantialdifferencesintheneedprofilesofdifferentpartsofthecounty,whichmakesitdifficulttoproduceasinglehealthandwellbeingstrategy.

Theclinicalcommissioninggroupsareonlyatanearlystageofdecidingtheircommissioningpriorities.Thesearelikelytoinvolvechangestohospitalservices(aspartofawidersub-regionalreconfiguration)thatwillbeunpopularwithsomelocalpeople.Thelocalauthorityischannellingpublicconcernthroughitsoverviewandscrutinycommittee,andislikelyto‘agreetodisagree’onthisparticularaspectofNHScommissioningintentions.

Theboardagreestoadoptsomehigh-levelprioritiesdrawnfromtheexisting,separateplans,oneofwhichisbetterinformationandadvice.Anotableearlyquickwinisthatalllocalpublicserviceaccesspoints,fromlibrariestoGPsurgeries,agreetodisplaybasicsignpostinginformationtodiverthospitalattendancesandpromoteself-care.

Inthisscenario,recognitionofthemultiplicityofdifferentbodiesandtheirdifferentstartingpointsseestheboardtakeastrategicfocusontheoverallprioritiesthataresharedbyallpartners,butthesemaynotnecessarilyaddressthechallengesfacingthesystemasawhole.

Scenario 3 Passive engagement

PastrelationshipsbetweenthelocalauthorityandNHShavegenerallybeengood.Thecontrollingpoliticalpartyhasasmallmajorityandadoptsaconsensualstyleofleadership.

Becauseofthetraditionofgoodworkingrelationships,thehealthandwellbeingboardislargelyacontinuationoftheprevioushealthandsocialcarepartnership,withtheadditionofGPrepresentationfromthetwoclinicalcommissioninggroups.Useofhospitalandnursinghomeplacesiswellabovethenationalaverageduetoarapidlyageinglocalpopulation.Thelocalacutetrustfacesagrowingfinancialdeficit,withconcernsalsobeingexpressedaboutqualityofcare.

TheclinicalcommissioninggroupwaslatetobeauthorisedandstruggledtodevelopcommissioningplansthatwereacceptabletotheNHSCommissioningBoard.Itsengagementwiththeboardhasthereforebeenlimited.Asaresult,boardmeetingsaredominatedbysharingofexistingplansandstrategies,whichareusually‘rubber-



stamped’;mostmemberscontinuetovaluetheopportunitiesfornetworkingandtomaintainpastrelationships.Theytendtoattributelocalproblemstonationalpoliciesandinadequategovernmentfunding.

Thefinancialpositionoftheacutetrustcontinuestodeteriorate,andconcernsexpressedbyMonitorandtheCareQualityCommission(CQC)leadtotheNHSCommissioningBoardinitiatingdiscussionswithaneighbouringtrustaboutamerger.

Inthisscenario,theboardislargelyirrelevantinanunfoldingcrisisoffinancialandservicefailure,withlittleinfluenceorimpactonthemajordecisionsthatwillneedtobemade.

Next steps

Theliteratureandevidenceonpartnershipworkingillustratetheprofoundchallengesinachievingeffectivecollaborationandthefactthatpotentialbenefitshavebeenhardtorealise.Theoutcomesachievedbyhealthandwellbeingboardswilldependonarangeoffactors,includingnationalpolicyandlocalcircumstances,andtherearelikelytobewidevariationsfromoneplacetoanother.Ourfindingsandanalysisindicatesomecommonthemesandissuesemergingfromtheearlyimplementersthatneedtobeaddressedbytheboardsthemselves,theirpartners,andtheDepartmentofHealthinthewindowofopportunitythatistheshadowyear.

Mostlocalauthoritiesarestilldevelopingtheirwayofworking,tryingtosetupboardsthatarefitforpurposewithoutbeingtoolargeorunwieldy.Itwillbehardtogetthisbalancerightwheretherearetwotiersoflocalgovernmentandmultipleclinicalcommissioninggroups,andmanyarestillthinkingthroughhowthenewboardwilldovetailwithothervaluedlocalstructuressuchaschildren’strustsandsafeguardingboards.Theyneedtoaddressrisksthattheboardwillbeseensimplyasanadditionallayerofmeetingsthataddscostratherthanvaluetolocalpartnershiparrangements.Theshadowyearofferstimeforexperimentation,anditisvitalthatthereisrapidcaptureanddisseminationofwhatworksusingdifferentapproaches.

Theprimarypurposeofhealthandwellbeingboardsistopromoteintegratedcare,anditiswidelyagreedthatthisshouldbecomeamajorpolicypriority.InourrecentreportproducedwiththeNuffieldTrustfortheDepartmentofHealthandtheNHSFutureForum,wepointedoutthatcommissionersaloneareunlikelytodrivethedevelopmentofintegratedcareatthescaleandpacerequired(Goodwinet al 2012). Giventheevidenceonthedifficultiesfacedbycommissionersinenablingintegratedcare(CurryandHam,2010),itislikelythatmanyintegratedcarepartnershipswillbeledbyprovidersratherthancommissionersinthefirstfewyears(Goodwinet al2012).Yetmostboardsdonotincludeproviderrepresentatives,andwhilesomeboardshaveappliedimaginativethinkingindistinguishingboardmembershipfromwiderstakeholderengagement,itremainstobeseenwhetherthiswillbesufficientandcanbereplicatedelsewhere.Ifhealthandwellbeingboardsaretobeagenuinelynewandeffectivevehicleforintegration,itisvitalthatalllocalauthoritieslookafreshatwaysofworkingwithlocalpartners.Theymustavoidtheeasyrouteofuncriticallycarryingforwardpreviouspartnershiparrangements,withahardseparationofcommissionerandproviderroles.

Thisalsoraisesawiderquestionastowhethertheroleofhealthandwellbeingboardsneedstobemoresharplydefinedsothatthereisgreaterclarityaboutwhattheyaretryingtoachieve.Thepurposeoftheboardsistosetthestrategicframeworkforcommissioning–throughthejointstrategicneedsassessmentandhealthandwellbeingstrategy–andnottodirectlycommissionservices.However,theHealthSelectCommitteehasrecentlyarguedthattheboardsare‘…an obvious starting point for a radically strengthened



commitment to integrated health and social care commissioning’,andshouldhavethepowerstodevelopintegratedcommissioningbudgetsandapprovecommissioningplans(HouseofCommonsHealthCommittee2012).

Thereisadangerthatstrongeremphasisonoverseeingcommissioningwillhindereffortstopromoteintegratedcare.Aswehavenoted,mostboardsdonotincludeproviderrepresentationonthegroundsofpotentialconflictsofinterest.Incontrast,clinicalcommissioninggroupsareaddressingpotentialconflictsofinterestbetweenthecommissioningandprovidingrolesofGPsthroughthedevelopmentofdetailedgovernancearrangementsthatemphasisetheimportanceofoperatingtransparently,withspecificmeasurestosafeguardagainstanyconflictsofinterestthatmayarise(DepartmentofHealth2011a).Healthandwellbeingboardscouldtakeasimilarapproachtomanageanyconflictsofinterestwithproviders–butiftheyareadoptingastrategicrole,theseareunlikelytoarise.Boardsneedtogivemorethoughttowhatgovernancearrangementsarerequiredinordertofulfilltheirprimarypurposeofintegratingservices.

TherealsoneedstobefurtherconsiderationofhowtheroleofthenewboardswillbeaffectedbytheworkoftheNHSCommissioningBoard.Itwillbeasignificantcommissioneroflocalservices,yetrespondentsexpressedlittleoptimismthatthehealthandwellbeingboardswillhaveanyinfluenceonitsdecisions.Thisreflectswideruncertaintyabouttherespectiverolesofthehealthandwellbeingboards,clinicalcommissioninggroupsandtheNHSCommissioningBoard,andhowtheywillworktogether.Inamorecomplexorganisationallandscape,theserolesandresponsibilitiesneedtobemuchmoreclearlysetouttoavoidconflictandensurethattheprimarypurposeofthehealthandwellbeingboardsiswellunderstood.AnxietiesabouttheroleoftheNHSCommissioningBoardarefuelledbyadeepersuspicionamongrespondentsthat,despitetherhetoricoflocalism,nationalpolicyimperativescouldover-ridethelocalprioritiesagreedthroughhealthandwellbeingboards.Thiscouldleadtolossofinterestin,andcommitmentto,thelocalboard.

Intheirstrategicroles,healthandwellbeingboardswillbegrapplingwiththetensionsbetweennationalprioritiesarisingfromthemandatetotheNHSCommissioningBoardfromtheSecretaryofStateforHealth,andamorepermissiveregimeinwhich152separatelocalauthoritiesindependentlydeterminetheirownspendingandcommissioningpriorities.Aswellasthesestructuraldifferences,manyrespondentsemphasiseddifferentculturesandwaysofworkingwithindifferentpartsoftheNHSandlocalauthorities.Tooperateasaunifiedstructure,workingtoanagreedsetofpriorities,localboardswillneedtofindwaysofovercomingthesedifferences.Aswehaveseen,thecreationoflocalhealthandwellbeingboardswilldonothinginitselftochangethesefundamentaldifferences,andtheimplicationsofthisdonotappeartohavebeenfullyappreciatedintheplanningstage.Wehavearguedthatthereneedstobeastrongernationalframeworkforintegratedcare–includingaclear,ambitiousandmeasurablegoaltoimprovepeople’sexperienceofservices–thatwillcreateapolicyandregulatoryenvironmentinwhichhealthandwellbeingboardscanachievetheirobjectiveslocally.Thisshouldincludeactiontodevelopasingleoutcomesframeworktopromotejointaccountability(Goodwinet al2012).

Thebiggestchallengeforthenewboardsiswhethertheywillsucceedindeliveringstrong,credibleandmatureleadership.AsthereportfromTheKing’sFundCommissiononLeadershipandManagementintheNHSpointsout:

The NHS needs leadership and management, not just ‘from the board to the ward’ – essential and central though that is – but across NHS boundaries into social care, local government, the voluntary sector and the wide variety of other agencies with which it interacts and without whose co-operation it will not achieve its primary objectives. This requires not heroic leadership but leadership that is shared, distributed



and adaptive. Leaders must focus on systems of care and not just institutions and on engaging staff and followers in delivering results. Leadership development should focus on organisations and systems, not simply individuals, and should give much more attention to shared leadership between managers and clinicians.

(TheKing’sFund2011,p28)

Itisveryearlytopredicthowhealthandwellbeingboardswilloperateinpractice,whatimpacttheywillhave,andwhethertheywillachievetheconsistentandgeographicallyuniformsuccessthathaseludedpreviousinitiativesoverthepast40yearsandmore.Theinterviewsonwhichthisreportisbasedtookplaceinautumn2011,andthereisstillmorethanayeartogobeforetheboardsbecomefullyoperational.Ourfindingsreflectalargelypositiveviewofprogresssofar,butouranalysissuggeststhatifboardsaretogrowintomaturepartnershipsdeliveringlocalleadershipandservicechange–our‘systemleadership’scenario–muchmoreworkisneededatnationalandlocallevels,especiallytodevelopastrongerframeworkforintegratedcare.



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DepartmentofHealth(2011d).The Operating Framework for the NHS in England 2012/13.London:DepartmentofHealth.Availableat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131360(accessedon4January2012).

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DepartmentofHealth(2010b).Liberating the NHS: Local democratic legitimacy in health. A consultation on proposals.London:DepartmentofHealth.Availableat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_118603(accessedon4January2012).

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GoodwinN,SmithJ,DaviesA,PerryC,RosenR,DixonA,DixonJ,HamC(2012).Integrated Care for Patients and Populations: Improving outcomes by working together.AreporttotheDepartmentofHealthandtheNHSFutureForum.London:TheKing’sFundandNuffieldTrust.

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Appendix 1: MethodologySeveralmethodswereusedtocollectdataforthisstudy:

n casestudiesbasedontwolocalauthorityareas(SurreyandLambeth)whereTheKing’sFundhadfacilitatedlocalworkshops

n astructuredtelephonesurveyconductedwithself-identifiedleadofficersforhealthandwellbeingboardsin50localauthorityareas

n afollow-upquestionnairesenttoalltelephoneinterviewees

n aliteraturereviewtoestablishcurrentknowledgeofimplementationoftheboardsandformerinitiativesintendedtopromotelocaljointworking.

Case studies

Aswellasdesigningandfacilitatingworkshops,fifteensemi-structuredinterviewswereconductedacrossbothauthoritieswithcontactsincludingcabinetmembers,clinicalcommissioninggroupleads,LocalInvolvementNetwork(LINk)leads,andPrimaryCareTrust(PCT)andlocalauthoritychiefexecutives.Intervieweeswereaskedaseriesofquestionscoveringtheirpastpartnershiparrangements,engagementwithstakeholders,currentprogressinestablishingthehealthandwellbeingboard,factorshelpingandhinderingdevelopment,andearlypriorities.

Telephone survey

n Apragmaticsamplingstrategywasconductedforthetelephonesurvey.All152upper-tierlocalauthorityareaswereidentified,groupedbyregionandauthoritystructure.Deprivationscoreswerecalculatedusingthe2010EnglishIndicesofDeprivation.Inordertoachievearepresentativemixtureoftypesofcouncil,regionanddeprivation,50authoritieswereinitiallyidentifiedandinvitationsweresenttothedirectorsofadultsocialservicesaskingthemtoidentifytheappropriatehealthandwellbeinglead.Othercouncilsfromtheremaininglistwerethenapproachedtotakepartinthesurveybasedontheirregion,structureanddeprivationscoresuntilasampleof50wasreached(30.4percentresponserate).

BetweenSeptemberandOctober2011,30-minuteconfidentialtelephoneinterviewswereconductedwith50self-identifiedleadofficersforhealthandwellbeingboards.Respondentswereaskedaseriesofstructuredquestionsandaskedtocompleteabriefpost-surveyquestionnaire.

Table A1 Sample characteristics

Regions Number

London 12

North East 3

North West 5

West Midlands 6

East 1

East Midlands 3

South East 4

South West 4

Yorkshire and the Humber 12

Total 50



Structure Number

Unitary authorities 17

Metropolitan districts 14

London boroughs 11

Shire counties 8

Total 50

Respondent characteristics Number

Director of social care (adult, children, combined role) 20

Assistant director/third tier 11

Directors of public health 7

Local authority chief executive or assistant 3

Other 9

Total 50

Follow-up questionnaire

Ashortquestionnairewassenttoall50participantsinthetelephonesurvey.Respondentswereaskedtoprovideadditionalinformationoncouncilandadultandsocialcarebudgetsin2011/12andtorestatethecategoriesofboardmembership.Forty-one(82percent)ofthelocalauthoritiessampledcompletedthefollow-upquestionnaire.



Appendix 2: Interview responsesWhatisyourlocalauthoritytype?

Local authority type Number

Metropolitan district 14

Shire county 8

Unitary authority 17

London borough 11

Total 50

Didyouhaveahealthandwellbeingboardorpartnershipinplacepriortoreforms(Y/N)?

Local authority type Yes No

Unitary authority 15 2

Metropolitan district 12 2

Shire county 5 3

London borough 10 1

Total 42 8

DoyouhaveajointDirectorofPublicHealth(Y/N)?

Yes 41

No 9

Total 50

Howlonghavetheybeeninpost(lessthan3months,3–6months,6–12months,morethanayear)?

Length of time in post Number

Less than 3 months 1

3–6 months 0

6–12 months 3

More than a year 37

Total 41

HowwouldyouratethecurrentworkingrelationshipbetweenthelocalauthorityandNHS(ratingscale1(poor)–6(good))?

Rating 1 2 3 4 5 6 Not sure Total

Unitary authority 0 0 1 9 6 0 1 17

Metropolitan district 0 0 2 6 5 1 0 14

London borough 0 0 2 2 4 2 1 11

Shire county 0 0 1 4 3 0 0 8

Total 0 0 6 21 18 3 2 50



Howmanymembersdoesithaveintotal?

Number of members Shire county London borough Metropolitan district Unitary authority Total

>12 2 4 4 11 21

13–20 5 5 8 5 23

20 + 1 2 1 0 4

Total 8 11 13 16 48

Canyoutellmeifthefollowingareontheboard?

Groups on the board Yes No Total

Clinical commissioning groups 49 0 49

Social care teams 48 1 49

Voluntary/third sector groups 28 21 49

Public health professionals 48 1 49

Hospital trusts and secondary providers 12 37 49

Public and patient involvement groups 45 4 49

District councils 6 2 8

Levelofengagementonascaleof1to6(1=poor,6=good).

Groups 1 2 3 4 5 6 n/a Total

Clinical commissioning groups 0 2 4 12 16 14 0 48

Social care 0 0 1 2 14 30 1 48

Voluntary/third sector groups 0 0 4 10 11 6 17 48

Public health 0 0 0 3 12 33 0 48

Hospital trusts and secondary providers 0 3 3 3 5 3 31 48

Public and patient involvement groups 0 1 8 7 19 10 3 48

District councils 0 0 1 1 2 1 3 8

Whowillbechair/co-chairandvice-chair?

Local authority structure Chair Vice-chair

London borough Councillor Chair of clinical commissioning groups

London borough Councillor Councillor

London borough Councillor Not yet decided (NYD)

London borough Councillor Councillor

London borough Councillor NYD

London borough Councillor NYD

London borough Leader of council Chair of clinical commissioning group

London borough Leader of council/Chair of NHS trust NYD

London borough Leader of council Chair of clinical commissioning group/Chair of HealthWatch

London borough Leader of Council Councillor

London borough Mayor NYD

Metropolitan district Councillor Leader of Council

Metropolitan district Councillor NYD

Metropolitan district Councillor Councillor



Haveanynewappointmentsbeenmadeinrelationtotheshadowboards(Y/N)?Ifyes,pleaseexplain.

From48responses:

Yes:6(12.5%)

No:42(87.5%)

Local authority structure Chair Vice-chair

Metropolitan district Councillor Chair of PCT board

Metropolitan district Deputy leader of council NYD

Metropolitan district Independent Chair of clinical commissioning group

Metropolitan district Leader of council Councillor

Metropolitan district Leader of council Deputy leader of council

Metropolitan district Leader of council NYD

Metropolitan district Leader of council Clinical commissioning group representative




Shire county Chair of NHS trust Leader of council

Shire county Chair of PCT/Councillor NYD

Shire county Councillor Vice chancellor of university/Chair of clinical commissioning group

Shire county Councillor NYD

Shire county Councillor Councillor

Shire county Councillor NYD

Shire county Councillor Lead of clinical commissioning group

Shire county Leader of council NYD

Unitary authority Chief executive NYD

Unitary authority Councillor NYD

Unitary authority Councillor Chair of clinical commissioning group

Unitary authority Councillor Chief executive for NHS cluster

Unitary authority Councillor Councillor


Unitary authority Councillor Director of public health

Unitary authority Councillor NYD


Unitary authority Deputy leader of council NYD

Unitary authority Deputy leader of council NYD

Unitary authority Director of public health Councillor

Unitary authority Executive member of council NYD

Unitary authority Leader of council NYD

Unitary authority Leader of council NYD

Unitary authority Mayor Chair of LINk

Unitary authority Superintendent commander of police NYD



Hastheboardmet(Y/N)?

From50responses:

Yes:40(80%)

No:10(20%)

Howoftendoyouplantomeet?

Frequency of meetings Number

Monthly 4

Every 6–8 weeks 31

Quarterly 5

Total 40

Healthandwellbeingboardsarerequiredtodevelopajointhealthandwellbeingstrategydetailingtheirplanstoaddressthehealthandwellbeingneedsofthecommunityandreducehealthinequalities.

Pleaserateonascalefrom1to6,with1beingtheworstand6thebest,howimportantyouthinkyourlocalhealthandwellbeingstrategywillbein:

a. influencingthecommissioningdecisionsofclinicalcommissioninggroups

b. influencingthecommissioningdecisionsoftheNHSCommissioningBoard.

Level of influence Clinical commissioning groups NHS Commissioning Board

1 0 1

2 1 12

3 7 9

4 7 8

5 21 0

6 9 1

Not sure 5 19

Totals 50 50

Howwouldyouratethecurrentusefulnessofthejointstrategicneedsassessmentonascaleof1to6,with1beingtheworstand6thebest?

Usefulness of joint strategic needs assessment Number

1 0

2 2

3 9

4 29

5 8

6 2

Not sure 0

Total 50



DoyouCOMPLETELYAGREE,SOMEWHATAGREE,NEITHERAGREENORDISAGREE,SOMEWHATDISAGREEORCOMPLETELYDISAGREEwiththefollowingstatements?

a. Thehealthandwellbeingboardwilldeliverontheprioritieswe’veidentified.

b. Thehealthandwellbeingboardwillleadtoincreasedpoolingofcommissioningbudgets.

c. ThehealthandwellbeingboardwillhelpachievecloserintegrationofservicesbetweenlocalauthorityandNHS.

d. Thehealthandwellbeingboardwillhelptoimproveco-ordinatedcarepathwayplanning.

Completely agree

Somewhat agree

Neither agree nor disagree

Somewhat disagree

Completely disagree

Total

The health and wellbeing board will deliver on the priorities we’ve identified

14 35 0 1 0 50

The health and wellbeing board will lead to increased pooling of commissioning budgets

13 29 6 2 0 50

The health and wellbeing board will help achieve closer integration of services between local authority and NHS

26 22 1 1 0 50

The health and wellbeing board will help to improve co-ordinated care pathway planning

17 26 6 1 0 50


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About the authorsRichard Humphries isSeniorFellow,SocialCareandLocalGovernmentatTheKing’sFund.RichardjoinedtheFundin2009toleadonsocialcareandworkacrosstheNHSandlocalgovernment.Heisarecognisednationalcommentatorandwriteronsocialcarereform,thefundingoflong-termcareandtheintegrationofhealthandsocialcare.HeisleadingtheFund’sworkonhealthandwellbeingboards,includingaresearchprojectandofferingpracticalsupporttoseverallocalauthoritiesandtheirhealthpartners.

AgraduateofLSE,hisprofessionalbackgroundissocialwork,andoverthepast35yearshehasworkedinavarietyofroles,includingasadirectorofsocialservicesandhealthauthoritychiefexecutive(thefirstcombinedpostinEngland)andinseniorrolesintheDepartmentofHealth.RichardisacolumnistfortheLocalGovernmentChronicle,anon-executivedirectorofHousing21andco-chairoftheassociates’networkoftheAssociationofDirectorsofAdultSocialServices.HeisalsoaFellowoftheRSA.

Amy GaleajoinedTheKing’sFundinAugust2011asaResearcher.Hermaininterestisexploringwaysinwhichtheintegrationofcarecanoccuratalocallevelinordertomakesuretheneedsofthemostvulnerableinsocietyarenotoverlooked.

ShejoinedtheFundfromtheClinicalEffectivenessUnitattheRoyalCollegeofSurgeonsofEngland,whereshesupportedtheirnationalauditworkbyundertakingdataanalysis.Priortothis,sheworkedattheCentreforRadiation,ChemicalandEnvironmentalHazardsattheHealthProtectionAgency,whereshecarriedoutanextensiveliteraturereviewfortheUK Recovery Handbook for Chemical Incidents.AmyholdsaMastersinpublichealthfromKing’sCollegeLondon.

Lara SonolaisaresearcherofhealthpolicyatTheKing’sFund.ShejoinedtheFundinJuly2009toworkonThePointofCareProgrammewhilecompletingherMasters.Sheiscurrentlyworkinginanumberofhealthpolicyareas,includingareviewofintermediatecare.Priortothis,sheworkedintheFacultyofMedicineatImperialCollege,London,duringtheestablishmentoftheUK’sfirstacademichealthsciencecentre.LaraholdsadegreeinbiomedicalsciencefromKing’sCollege,London,andanMScinpublichealth(healthservicesresearch)fromtheLondonSchoolofHygieneandTropicalMedicine.

Claire MundlejoinedTheKing’sFundinOctober2010asaPolicyOfficerandisresponsibleforco-ordinatingtheFund’sresponsivepolicywork,suchasconsultationsandbriefings.ClairejoinedtheFundfromNHSWestminster,wheresheworkedasapublichealthcommissioner.Herworkfocusedontacklinghealthinequalitiesandcollaboratingwiththevoluntarysectortodeliveronthisagenda.PriortothisshecompletedtheNHSGraduateManagementTrainingscheme,workinginbothprimaryandsecondarycaresettingsinanumberofmanagementroles.ClairehasanMScinHealth,PopulationandSocietyfromtheLondonSchoolofEconomicsandPoliticalScience.