Could health and wellbeing boards really work as a single commissioner?

When Health and Wellbeing Boards (HWBs) were introduced in local authorities (LAs) in 2012, their original purpose was to improve the health and wellbeing of local communities and reduce inequalities by promoting integration across health, care and other services.

While this original job description for HWBs did not include a commissioning role, the idea of HWBs as a facilitator of better joined-up commissioning across NHS services, social care and health improvement is rapidly gaining currency. 

A central component of Labour party health policy is ‘whole person care’ – a concept which supports HWBs becoming more involved in the commissioning process. There is also an appetite for this at a local level with 62% (40/65 responses) of HWBs surveyed by The King’s Fund expressing a desire to have a greater role in commissioning. 

Significant investment, or restructuring, may be needed to build up HWBs into lead commissioners, and to consider who holds them to account.

Last year, the Labour Party suggested HWBs could take on the commissioning of hospital care, primary care, mental health and public health; a proposal not welcomed by GPs. More recently, the Health Select Committee has encouraged the development of HWBs into ‘integrated commissioners’ and that this should happen with “minimum disruption of ongoing activity”. The HWBs role in signing off the joint Better Care Fund is considered, by some, as testing the waters. 

There is more support for HWBs having a stronger role from the recent Barker Commission. The commission recommended there should be a joint health and social care budget and a single local commissioner for health and social care - a viewpoint few oppose. Deciding who takes on the role as single commissioner was beyond the scope, but the report did suggest that HWBs could offer an attractive solution. 

"We recommend that work be undertaken to explore whether the Health and Wellbeing Boards could evolve into the single commissioner." Barker Commission. 

So could HWBs be effective commissioners?

…they have some attributes which suggest they could. The principles of the HWBs include shared leadership and accountability, parity between members (including an increasing number of providers), commitment to improving services, and openness and transparency – all factors which encourage joint working. HWBs also have a legal duty to promote integration and the use of pooled budgets. 

From what I have experienced, the value of the HWB is in its members – discussing, influencing and negotiating - largely outside of the formal meetings, building collaborative working relationships between their respective teams. 

But effective commissioning is much more than collaborative working. It’s a complex set of processes including decisions on resource allocation, contract negotiation, monitoring and review. Developing health and social care services under a single budget is a daunting task, requiring strong leadership and commissioning skills to deliver its true potential for patients. But, “there is little sign as yet that boards have begun to grapple with the immediate and urgent strategic challenges facing their local health care systems”. Concerns have also been raised about HWBs ability to hold services to account and scrutinise decisions. This suggests that significant investment, or restructuring, may be needed to build up HWBs into lead commissioners, and to consider who holds them to account.

We should not underestimate the skills required to commission effectively. We need a better understanding of how this differs from the current HWBs role; and the level of investment required to ensure future commissioning is fit for purpose. Nor should we discount alternative options: could the same be achieved by strengthening partnerships and joint commissioning across LA and Clinical Commissioning Groups (CCGs)? 

Thinking about it, I’ve generated more questions than answers. If you’re interested in the changing role of HWBs and want to get involved in the debate, why not go along to the HWB meetings at your local council (they’re open to the public)?