The future of health and wellbeing strategies
A great unfulfilled potential of the 2012 health reforms was a health and wellbeing strategy agreed jointly by the local authority, CCG, Healthwatch and others on the Health and Wellbeing Board (HWB). This was an opportunity to look long term not just at health and social care but also at the many social determinants of health and to turn the rhetoric of ‘prevention’ into a reality.
In practice, local areas did not rise to the challenge. I have speculated on the reasons but I suspect that it was largely because no model for what such a strategy might look like was produced and in the context of savage cuts imposed on local government and financial settlements in the health service that did not keep up with demand, there was not much slack to do some original thinking.
In the light of this, I was expecting that the requirement to produce a Joint Health and Wellbeing Strategy (JHWS) would have been quietly dropped in proposals for new legislation. But no, the recent health and care White Paper (1), says that Health and Wellbeing Boards and the Joint Health and Wellbeing Strategy will remain.
But what will, could and should such strategies look like in the context of Integrated Care Systems? First of all, it is clear that the Joint Health and Wellbeing Strategy is to stay:
“Health and Wellbeing Boards will remain in place and will continue to have an important responsibility at place level to bring local partners together, as well as developing the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy, which both HWBs and ICSs will have to have regard to.” 6.18, (b), p.73.
(The HWB has to have regard to the JHWS – but it is the body that has produced it! The current legislation is that the local authority and the CCG, as individual, constituent bodies, have to have regard to it.)
That seems to suggest that the JHWS has primacy as the strategy that others have to have regard to.
However, there will also be a strategy setting role at ICS level. The ICS has two parts: the ‘ICS NHS Body’ (the management body that takes on the functions of the CCG) and the stakeholder partnership board, the ‘ICS Health and Care Partnership’, and both have a role in regard to strategy and planning.
The role of the ICS NHS Body is:
- “developing a plan to address the health needs of the system;
- setting out the strategic direction for the system; and
- explaining the plans for both capital and revenue spending for the NHS bodies in the system.” (6.18, (g), p.74)
(The distinction doesn’t seem to be clearly made throughout the document between a plan and a strategy.)
Both the ICS bodies have to have regard to the ‘HWB plans’.
“We also recognise the importance of bringing together ICSs and Health and Wellbeing Boards (HWB) as complimentary [sic] bodies at system and place level. ICS NHS Bodies and Health and Care Partnerships will have formal duties to have regard to HWB plans …” (5.101, p.55).
(It’s nice to know there will be mutual admiration between the two levels!) But by ‘HWB plans’, do they mean the JHWS or any plan that the HWB produces?
However, it turns out that the JHWS is not the primary strategy.
“The ICS will also have to work closely with local Health and Wellbeing Boards (HWB) as they have the experience as ‘place-based’ planners, and the ICS NHS Body will be required to have regard to the Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies that are being produced at HWB level (and vice-versa).” (5.11, p.35).
So that suggests a reciprocal relationship; that the HWB in its JHWS (or more generally?) needs to have regard to the ICS NHS Body plan. But what about the ICS Health and Care Partnership? It too has a planning role:
“This Partnership would be tasked with promoting partnership arrangements, and developing a plan to address the health, social care and public health needs of their system. Each ICS NHS Body and local authority would have to have regard to this plan.” (6.19, p.74)
So the local authority, but not the whole HWB would have to have regard to it? (Is this because the CCG is now in the ICS so has to have regard to it, and who cares about the other members of the HWB?).
So, to sum up, all three bodies will have a strategy setting role and have to have regard to the others, except, unless I’ve missed it, the ICS Partnership doesn’t have to have regard to the ICS NHS body plan.
This all sounds a little confusing. Would it be unfair to suggest it hadn’t been properly thought through? If so, that may be because the bulk of the White Paper doesn’t seem to have been generated from within the Department of Health and Social Care. It seems to be more a game of ‘Simon says’.
Or is it just that it hasn’t been clearly drafted? Neither explanation is terribly encouraging. Let’s hope it’s a third option, that it’s actually perfectly clear and fits together well but I just haven’t properly understood it. In any event, it will almost certainly become clearer when the Bill is produced, when more attention will have to be paid to the detail.
I suspect that what will emerge in the legislation is that the partnership body will have an overall strategic role with the NHS body producing a strategy delivery plan.
But what ought the respective roles be, particularly between ICS and local authority levels?
The obvious distinction would be for the ICS Partnership body to have responsibility for broad strategic direction – such as the aim to move to more prevention, developing the role of PCNs to provide integrated, whole-person care, objectives in relation to technology and so on. That strategy would be produced with the input of each place within the ICS, so their views and interests would already be taken into account.
At ‘place’, or HWB level, the strategy would put some flesh on those bones in terms of delivery and take account of differences between areas (e.g. urban vs rural, levels of deprivation, history of the area and its organisations, etc.).
All of this would be in the context of a national strategy co-produced between central government, local government, the health service, the private sector, the voluntary and community sector and the public.
But if any of this is to work, there needs to be a much better sense of what a strategy would look like and how it could be effective. And I have not yet seen evidence of the existence of that.
(1) Department of Health and Social Care, Integration and Innovation: working together to improve health and social care for all, February 2021, https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all