MIDDLESBROUGH COUNCIL

Middlesbrough Health and Wellbeing Board – Review and future structure

Executive Member for Finance and Governance: Councillor Nicola Walker

Executive Director of Commercial and Corporate Services: Tony Parkinson

1 December 2015

PURPOSE OF THE REPORT

  1. To outline findings from the recent review of Middlesbrough’s Health and Wellbeing Board and propose changes to the Health and Wellbeing Board structure to address these findings and associated issues.
SUMMARY OF RECOMMENDATIONS
  1. That the proposed new structure for the Middlesbrough Health and Wellbeing Board and its associated partnerships (Option 3) outlined at Appendix 2 and set out in this report is agreed and implemented formally from the 2016/17 municipal year.

IF THIS IS A KEY DECISION WHICH KEY DECISION TEST APPLIES?

It is over It is over the financial threshold (£150,000)
It has a significant impact on 2 or more wards
Non Key / X

DECISION IMPLEMENTATION DEADLINE

  1. For the purposes of the scrutiny call in procedure this report is

Non-urgent / X
Urgent report

If urgent please give full reasons

BACKGROUND AND EXTERNAL CONSULTATION

Background

  1. Health and Wellbeing Boards (HWBs) were introduced as statutory committees of all upper-tier and unitary local authorities under the Health and Social Care Act 2012.HWBs are intended to:
  • improve the health and wellbeing of the people in their area;
  • reduce health inequalities; and
  • promote the integration of health and social care services.
  1. The 2012 Act prescribes a core statutory membership of:
  • at least one elected representative, nominated by either the leader of the council, the mayor, or in some cases by the local authority;
  • a representative from each Clinical Commissioning Group (CCG) whose area falls within or coincides with, the local authority area;
  • the local authority directors of adult social services, children’s services and public health;
  • a representative from the local Healthwatch organisation; and
  • a representative of NHS England to assist in the preparation of Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWS) and to consider NHS England’s own commissioning functions.
  1. Two or more CCGs may be represented by the same person on the HWB. Boards can add members beyond that set out in the legislation. This can include representatives from other groups or stakeholders who can bring in particular skills or have key statutory responsibilities which can support the work of boards.
  1. HWBs have a statutory duty to oversee the production of JSNA and JHWS setting out joint priorities for local commissioning. Local authority, CCG and NHS England commissioning should be aligned with these documents. CCGs are required to include relevant HWBs in the preparation of their commissioning plans and HWBs’ opinion must be published within the final commissioning plan.
  1. HWBs also have a duty to promote integrated working between the NHS and the local authority. They are empowered to encourage bodies involved in the wider determinants of health, such as housing, to work closely with commissioners of health and care services as well as with the HWB itself. As part of this role, HWBs have been given responsibility for overseeing their area’s planning for the Better Care Fund, set up by the previous government to increase the scale and pace of integrated working within localities and, in particular, to reduce hospital admissions and length of stays in hospital.
  1. Local authorities can delegate some of their functions and the associated funding to their HWB. CCGs can contribute to pooled budgets through transferring funding to local authorities through Section 256 of the NHS Act 2006 and local authorities and CCGs can operate pooled budgets through Section 75 of the NHS Act 2006.
  1. In addition to the specific statutory powers accorded to HWBs, local authorities also have a power of wellbeing under the Local Government Act 2000, enabling them to do anything they consider likely to promote or improve the economic, social or environmental wellbeing of an area. More recently, councils have been given a General Power of Competence under the Localism Act 2011. This gives councils the power to extend their services and support beyond the arena traditionally seen as the responsibility of authorities like them.
  1. CCGs also have the flexibility within their legislative framework to decide how far to carry out their commissioning and other functions themselves, in groups or jointly with local authorities. They have specific duties to act with a view to continuous improvements in services and to integration, to have regard to the need to reduce health inequalities and to promote innovation in the provision of health services.

Middlesbrough Health and Wellbeing Board

  1. Middlesbrough Health and Wellbeing Board has existed in shadow form since August 2011 and became a formal committee of the Council in April 2013. Chaired by the Mayor of Middlesbrough, it meets four times per annum.
  1. The Board adopted the Middlesbrough Health and Wellbeing Strategy in October 2012. The Strategy’s vision is “to improve the health and wellbeing of our local population and reduce health inequalities”. The Strategy has four aims, and the Board has delegated responsibilities for these to four Delivery Partnerships, as set out below.

Aim / Delivery Partnership / Chair
1 / Tackle the social causes of poor health / Wellbeing in Middlesbrough / Chris Smith, Group Director of Business Development, Thirteen Group
2 / Ensure children and young people have the best health and wellbeing / Children and Young People / Janet Lucas, Head Teacher, Green Lane Primary School
3 / Reducing preventable illness and early death / Public Health / Edward Kunonga, Director of Public Health, Middlesbrough Council
4 / Ensuring high quality, sustainable and joined up health, social care and wellbeing services / Health and Social Care / Richenda Broad, Executive Director of Wellbeing, Care and Learning, Middlesbrough Council
  1. The Delivery Partnerships also address other statutory duties around joint working on social issues placed upon the Council and its partners:
  • The Crime and Disorder Act 1998 places a duty on local authorities to work with the Police and other partners to assess and address crime and disorder in their areas. The Wellbeing in Middlesbrough Delivery Partnership is responsible for putting in place arrangements to meet this duty.
  • The 2010 Child Poverty Act places a duty on local authorities to prepare a ‘local child poverty needs assessment’ setting out the needs of children living in poverty in the area, and to prepare a child poverty strategy to address these needs. The Wellbeing in Middlesbrough Partnership is also responsible for putting in place arrangements to meet this duty.
  • The Children Act 2004 places a duty on local authorities to develop partnerships to improve children’s lives. The Children and Young People Delivery Partnership is responsible for putting in place arrangements to meet this duty.
  1. The Council’s Chief Executive has delegated responsibility for ensuring that these duties and functions are fulfilled, and in coordination with Delivery Partnership Chairs, provides an assurance report to each Board meeting outlining progress.
  1. Community engagement in the work of the partnership is achieved through two key channels:
  • The Health and Social Care Act 2012 required local Healthwatch to be established in April 2013. Healthwatch is the new consumer champion for health and social care.
  • Stakeholder Forums are held when required to consult and engage with the whole partnership structure and local communities on key issues.
  1. The Council has statutory responsibilities in relation to the safeguarding of children and vulnerable adults:
  • The Children Act 2004 requires local authorities to establish a Local Safeguarding Children Board (LSCB) for their area. The LSCB has a range of roles and statutory functions including developing local safeguarding policy and procedures and scrutinising local arrangements.
  • The Care Act 2014 introduces new safeguarding duties for local authorities including: leading a multi-agency local adult safeguarding system; making or causing enquiries to be made where there is a safeguarding concern; hosting safeguarding adults boards; carrying out safeguarding adults reviews; and arranging for the provision of independent advocates.
  1. Middlesbrough Safeguarding Children Board was established in April 2010. The MSCB has its main meetings every two months and has a number of associated Task Groups, which are linked to the core functions of LSCBs.
  1. In readiness for the requirements of the Care Act, an agreement was made in 2013 for the four unitary authorities on Teesside to jointly have one statutory Safeguarding Adults Board in preparation for statute on 1 April 2015. The purpose of the Board is to work in partnership to safeguard and promote the well-being and independence of adults at risk of harm or abuse living in the Boroughs of Hartlepool, Middlesbrough, Redcar & Cleveland and Stockton-On-Tees. The TSAB will co-ordinate and monitor the effectiveness of partner organisations working together to implement their responsibilities for protecting adults whose independence is placed at risk by significant abuse or neglect.
  1. The structure of the Middlesbrough Health and Wellbeing Partnership provides for recommendations from the Council’s scrutiny functions, Local Healthwatch and Local Safeguarding Boards to be considered and addressed.
  1. The above described arrangements (outlined at Appendix 1), which have been in place since June 2013, and established the HWB as the overarching strategic partnership within Middlesbrough, replacing the former LSP and co-opting other previous associated partnership arrangements as either Delivery Partnerships or workstreams of the new structure.

Health and Wellbeing Board Review

  1. In late 2014 / early 2015, HWB partnersparticipated in a development programme, commissioned by the Council via the Institute of Local Governance, and delivered by Durham University’s Centre for Public Policy and Health, to help individuals and organisations engaged in delivering the Health and Wellbeing Strategy understand how they can maximise the impact of their partnership working.
  1. The review found that there was some room for improvement in partnership activity, and the main findings arising were:
  • the importance of acknowledging the role of the political, organisational and economic context, in terms of acting as an impediment to progress;
  • the existence of various threats and enablers to ensuring connectivity across the health and wellbeing system;
  • the importance of getting the process right, while remaining outcomes-focused rather than process-driven; and
  • the need to make partnership working engaging and satisfying to ensure that partners remain motivated.
  1. The review found that the Middlesbrough health and wellbeing system is wrestling with the same issues as other similar systems across the country. The findings of this research are supported by those of previous studies, which have highlighted the difficult task faced by HWBs in bringing together many siloed agendas and organisations impacting on health and wellbeing. They face complexity, competing policy and financial drivers, and the pull of different organisational priorities.
  1. In Middlesbrough’s favour are the commitment and pragmatism of the individuals involved. The challenge revolves around how to be successful in spite of factors that mitigate against success. These require an alert and conscious approach to partnership working that includes:
  • having a strong narrative or vision from the HWB;
  • being comfortable with complexity and ambiguity about responsibilities;
  • focusing on a small number of things at a time;
  • keeping parts of the system connected to each other through central coordination and effective communication, such as good, concise, readable briefings;
  • managing Delivery Partnerships so that individual meetings are purposeful, engage everyone, leave room for healthy debate and hold each other to account for progress; and
  • recognising that people will make this work and that work therefore needs to be done to keep their energy and interest stimulated and successes acknowledged.
  1. Participants identified a number of practical ways forward for the Middlesbrough health and wellbeing system. These suggestions can be located on a spectrum from practical, quick and easy-to-implement ideas (e.g. meet more often, break into sub-groups, good chairing, clear/structured agendas, building in learning from other local areas) to longer-term and more complicated changes (e.g. giving the HWB more powers, putting health and social care into one integrated organisation, creating a Tees Valley-wide HWB or combined authority).
  1. In the short term, it will be important to review the existing partnership structures and ensure that there is clarity with regards to the purpose of each structure and the expectations of different partners. Participants in the Delivery Partnership workshops suggested that membership should be reviewed and refreshed on a regular basis, to ensure that the right people are around the table in terms of being able to implement any actions agreed.
  1. There should be sufficient central coordination and support to ensure that partners in the system can see how their contribution relates to the overall successes of the HWB, to reduce the potential for overlap and duplication, and to facilitate reporting between parts of the system as necessary.
  1. A key issue to arise from this research is that much of the ‘real work’ is seen as going on elsewhere, in terms of a range of other partnerships, agencies and services doing the ‘hands on’ work to improve health and wellbeing in Middlesbrough. The focus for the DPs should be on areas of joint working, rather than on discussing work that proceeds in separate silos. Another issue involves the sharing of good quality data, which underpins successful joint working. There is a need to devise and agree local data sharing arrangements to ensure that the HWB and DPs have access to the evidence needed to inform their work.
  1. The HWB and DPs need to spend time on action planning to achieve real clarity in terms of their short-, medium- and longer-term outcomes. There needs to be agreement on timeframes and key milestones, as well as the metrics and indicators used to monitor progress. Establishing a set of focused action plans and performance measures is one of the key activities identified in previous work, in the context of areas still requiring attention by many HWBs. Future development work in Middlesbrough might focus on revisiting these areas or reinforcing the outcomes, building on previous learning and achievements rather than starting afresh.

‘Making it better together’

  1. The Local Government Association and NHS Clinical Commissioners have recently published Making it better together A call to action on the future of healthand wellbeing boards. This document envisions a future for HWBs as health and care system leaders, rather than information exchanges, and sets out criteria for effective place-based boards, as set out below.

Shared leadership

  • an equal partnership of local commissioners with mutual recognition of the skills that each partner brings to the table;
  • a willingness to move away from institutional cultures and ways of doing business towards a common understanding of what matters;
  • bringing together a wide range of local and national agencies to make a demonstrable impact on outcomes;
  • designing and delivering services that take account of the wider determinants of health; and
  • recognition of the crucial role of providers in identifying solutions to local health challenges.

A strategic approach

  • shared ownership of a strategic approach to joined-up commissioning;
  • focusing on a manageably small number of local priorities that will have maximum impact on health outcomes;
  • designing services which are population-orientated, co-designed, person-centred, addressing inequality and disadvantage, and based on evidence;
  • focusing on services which are integrated, accessible, innovative, safe and of high quality; and
  • working at a pace and scale that makes sense locally, for example, building on existing community provision and conforming with local planning priorities for the area.

Engaging with communities

  • working with local communities in developing a vision and strategies for service design and redesign; and
  • being jointly accountable to local residents.

Collaborative ways of working

  • openness and transparency in the way they operate;
  • pooling and sharing risks as well as budgets where mutually agreed;
  • sharing data and intelligence;
  • having good working relationships with service providers;
  • making and encouraging the best possible use of new technologies; and
  • sharing information to monitor progress and measure impact.
  1. The document also sets out a series of asks to Government around budgeting, information governance, accountability across the system, a focus on joint outcomes and a joined-up and cohesive workforce.
  1. The LGA offers a Peer Challenge for HWBs based on the criteria set out above.As the document largely reprises the findings of the review work undertaken by Durham University, it is not proposed that the Council commissions a Peer Challenge at this stage, though consideration should be given to doing this within the next 12-24 months. This will be added to the HWB’s forward plan.

Discussion with partners

  1. A HWB development session was held in April 2015, facilitated by the review team, to discuss the findings from the review. The output from this session clarified the key issues of partners:
  • The current design of the HWB is not conducive to effective joint working. There is a lack of genuine joint planning and joint working within the structure, and to a great degree plans tend to reflect the existing plans of individual partners.
  • There is a view that subsuming all partnership working within the HWB structure has not been effective and has blurred focus – in effect that the agenda is too broad for the structure that was created to govern it. As a result partnership initiatives are starting to crop up outside of the formal governance structure.
  • The HWB does not meet frequently enough and consideration should be given to meeting every one or two months. Some partners feel that partnership working is affected by the fact that the HWB is a Committee of the Council.
  • Some Delivery Partnerships lack clear purpose and direction. Initiatives that clearly should be reporting into the HWB (e.g. South-Tees integration) currently do not do so.Those Delivery Partnerships that continue should in future focus on areas of genuine joint working only.
  • There is insufficient coordination and support for current partnership working, and it is not solely the role of the Council to provide this. Much more joint-working is required on performance management and data sharing, for example.
  • In addition to the above, there is the sense that partnership working at larger geographical levels (e.g. the Combined Authority negotiations) will have as-yet-unknown implications for local partnership working and the HWB will have to restate its purpose within this new landscape.

Recommendations