Health Service Focus

Inherent tensions – but good relationships

Richard Humphries, assistant director for policy at The King’s Fund, talks to NHE about the latest research into health and wellbeing boards.

Health and wellbeing boards (HWBs) became fully operational on 1 April 2013, and expectations have “never been higher”, according to The King’s Fund.

Its latest research into how they are performing, led by Richard Humphries, shows excellent relationships with CCGs and, for the most part, the right people on the boards – but also suggests that the “inherent tensions” between the board’s strategic, oversight and commissioning roles are causing some confusion, and that NHS England is still seen as an overseer rather than an equal partner.

When the boards were asked about the factors hindering them in achieving their objectives, the financial climate got far and away the most mentions, followed by national control/politics. Lack of clarity and silo working was the only other factor to get a significant amount of mentions.

Humphries told NHE: “Everything becomes tougher when there is less money; bear in mind that the NHS got used to a decade of annual real-terms growth increases, and suddenly that’s gone into reverse.”

He said that, coupled with the “absolutely unprecedented” scale of budget cuts in local government, meant “everything becomes 10 times harder”.

Some people like to say the financial climate is a burning platform forcing radical change, but for those actually dealing with the consequences, shrinking budgets are almost invariably seen as a problem rather than an opportunity, Humphries told us – “which is very understandable”.

Asked about the tensions some HWBs are experiencing, Humphries said how much to engage with providers was one key issue.

He said: “They’re being asked to promote integration, which suggests needing to get providers round the table; but they’re also being told they have a duty to produce the joint strategic needs assessment and strategic framework for commissioning, and a lot of boards are interpreting that as requiring them to stay at arm’s length from providers.

“There are inherent tensions there, and you’ve also got this faultline of the role of NHS England.

“It has a dual function – it should be around the table as an equal partner in the board, but in reality people are still seeing it as a hierarchical performance manager.

“We don’t sense that NHS England is seen as an equal partner in local commissioning. There’s a lot of uncertainty.”

Overcoming those tensions and that uncertainty, Humphries said, cannot just be left to the HWBs to work out. “If this government or a future government wants boards to play a clearer and stronger role in overseeing commissioning and pushing forward on integration, then it’s going to have to sharpen up and be much clearer in its steer, without going to the other extreme of being completely over-prescriptive.

“There’s a sense that the pendulum has swung too far towards localism; that the boards are being left to make it up for themselves, whereas you do need a national framework.”

The report adds: “The government intends that boards should ‘sign off’ on local plans for the use of the new £3.8bn Integration Transformation Fund. Although this represents only 3% of the combined total NHS and adult social care budget, in the current financial climate it is a substantial sum that offers boards an unprecedented opportunity to shape key spending decisions. This development could also be used by boards as a stepping stone to their overseeing the total health and social care budget in time.”

Humphries explained: “A problem with the current reforms is that commissioning has become fragmented.

“There is a potential role for the HWBs in bringing together resources, so you’ve got one single decision-making body. We’d argue that you need to tackle that in an evolutionary way and it needs to proceed on the basis of a partnership between CCGs, local authorities and NHS England, and not a take-over.”

There was a danger there, he said, in being seen to take powers away from CCGs just as they’ve finally acquired some, and “at a time when the need for GPs engaged in all of this has never been greater.” He said: “We’d urge caution and an evolutionary approach.”

The survey did suggest excellent relationships between the HWBs and CCGs – though Humphries joked that that mood might have changed since the ITF announcement, as most of its cash is coming out of CCG allocations. He added: “The problem in recent years has not been poor relationships per se, it’s been money, and the impact of reorganisation. This isn’t just about getting on well and holding hands and walking into the sunset: it’s about producing deliverable, demonstrable improvements. The test now is to convert good relationships into positive improvements.”

The boards need to be about “relationships, not meetings”, Humphries said, and focused on action not bureaucracy. The fact they tend to be supported by the local authority’s committee services is “both a blessing and a curse”, as the boards have good governance, but sometimes too much emphasis on “getting the agenda right and ticking the boxes rather than impact and outcomes.

“You do need both, you’ve got to have the right processes, but there is a danger in local government committee structure that the means become more important than the ends."