The NHS and local government: love thy neighbour?

During the early days of sustainability and transformation partnerships (when the P was still for Plan rather than Partnership) relationships between the NHS and local government were often far from neighbourly.

Even now, in some parts of the country, tensions remain, as reported by HSJ recently in Leicestershire. Yet, a new analysis from The King’s Fund, published last week, suggests that, in some areas, Health and Wellbeing Boards are proving to be a catalyst for improving relations.

Catalysts for improvement

This may sound surprising: HWBs were set up by the 2012 Act to be the key forum where local health and care leaders could work together to integrate care, but they failed to get traction in many areas.

More recently, while collaboration has become the expected way of working, new forums (and acronyms) have proliferated – whether Integrated Care Systems, Integrated Care Providers or the various boards and committees that surround them – seemingly leaving HWBs on the margins. However, predictions that ICSs will totally eclipse HWBs may be premature.

Our analysis – alongside a forthcoming report from Nick Timmins exploring the experience of leaders working across ICSs and STPs – underlines the progress being made in improving the relationships between the NHS and local government.

Despite the many barriers that exist, including differences in culture and accountability, and the added challenge of complex overlapping geographies in many cases, local leaders are often finding ways to work together to improve the health of the populations they serve.

 The governance role-play 

In the areas we looked at, NHS leaders were very positive about the benefits of working with local government colleagues and several felt their ICS had developed in unexpected and better ways as a result.

This included helping ICSs to “soften” the top down nationally driven approach of the NHS with an emphasis on finding local solutions to locally agreed needs and priorities. Equally, they were quick to recognise that this wasn’t always plain sailing and required continuous effort on all sides to manage cultural and other differences.

There is, of course, significant variation in relations across the country and wide variation in the wiring local systems have put in place to support collaboration. In some areas, HWBs are being used as a key vehicle for this. This often involves them playing a role in “place” level governance – as the footprint of “place” and HWBs often align, this can make them a readymade forum to push forward on integration.

HWBs often play a role in “place” level governance – as the footprint of “place”, making readymade forum to push forward on integration

Some have also become part of “system” (ICS) level governance, often involving several HWBs coming together. For example, the eight local authorities in West Yorkshire and Harrogate are working together to bring the local government voice to the ICS while the two HWBs in Coventry and Warwickshire have an agreement to work together to contribute to the STP.

In Suffolk and North east Essex, a joint assurance meeting was recently held to review and assess the new five-year system plan involving the chairs of both councils’ HWBs, overview and scrutiny committees and the NHS England and Improvement regional team. This sense of local ownership and shared oversight of the system plan stands in stark contrast to the first round of STP plans (and still rumbling discontent about the new plans in some areas).

Change – the only constant

The recent proposals for legislative change put forward by NHS England and Improvement made clear that ICSs should work with HWBs. This provided welcome recognition of their potential future role while avoiding the temptation to put forward a national blueprint for how this should be achieved. Building on this, we have highlighted three areas that need attention to enable local government and HWBs to make a full and effective contribution to ICSs.

First, the promised statutory guidance on ICS joint committees should reinforce the positive role of local government and should avoid stifling the scope for local arrangements that have driven much of the progress so far.

Second, the current role and functions of HWBs should be reviewed and refreshed, and consideration should be given to whether any changes would improve their effectiveness. This might include strengthening NHS membership and engaging boards more over budgets and decision-making, subject to local agreement.

And finally, local authorities can learn from the experience of their colleagues in the first ICSs by making sure they are working together to offer a strong local government contribution to their local ICS, based on a shared vision for improving the health and wellbeing of their local population.

The potential win to population health from bringing together the NHS, social care and the wider powers of local government over housing, public health and planning is simply too great to ignore. So while in many places this may feel like a slow process, getting to know (and love) your neighbour is not only important, it is essential.