Guidance

Health and wellbeing boards: draft guidance for engagement

Updated 22 November 2022

Applies to England

Summary

Health and wellbeing boards (HWBs) have been a key mechanism for driving joined-up working at a local level since they were established in 2013.

Since then, the Health and Care Act 2022 has introduced new architecture to the health and care system, specifically the establishment of integrated care boards (ICBs) and integrated care partnerships (ICPs). In this new landscape, HWBs continue to play an important role in:

• instilling mechanisms for joint working across health and care organisations
• setting strategic direction to improve the health and wellbeing of people locally

The Department for Health and Social Care (DHSC) will therefore be updating the guidance on the HWBs general duties and powers to provide information on how HWBs currently work and clarify their role within the system – including working with ICBs and ICPs.

This engagement document therefore contains draft guidance and a series of engagement questions. We welcome responses to these questions to:

• shape the guidance
• provide practical examples of the roles and ways of working of HWBs

Purpose

This draft guidance on HWBs has been updated to align with the Health and Care Act 2022 and Health and social care integration: joining up care for people, places and populations white paper (published February 2022).

It provides:

1. Background and context for this draft guidance.
2. Information on how HWBs currently work.
3. Clarification about their role post-1 July 2022, and the respective roles and duties of ICBs and ICPs and how they work in partnership with other HWBs.

This guidance should support ICB and ICP leaders to understand how they should work with HWBs to ensure effective system and place-based working, without being constrained or influenced by hierarchical approaches.

It also complements established guidance and signposts to other relevant new guidance.

Background and context

Promoting integrated person-centred care and health promotion is a key objective of:

• the DHSC’s adult social care reform vision
• the Health and Care Act 2022
• the NHS Long Term Plan
• the DHSC’s integration white paper Health and social care integration: joining up care for people, places and populations

HWBs:

• provide a strong focus on establishing a sense of place
• instil a mechanism for joint working and improving wellbeing of their local population
• set strategic direction to improve health and wellbeing

The Health and Social Care Act 2012 introduced HWBs, which became operational on 1 April 2013 in all 152 local authorities with social care and public health responsibilities.

Since then, the Health and Care Act 2022, which received Royal Assent in April 2022, looks to enable greater integration between partners across the health (which includes physical and mental health) and social care sector. This includes collaboration between partners who can address the wider determinants of health by:

• removing barriers to data-sharing
• enabling joint decision-making and greater collaboration within the NHS, between trusts, and between the NHS and other systems partners – in particular local authorities

The new architecture, introduced by the Health and Care Act 2022, and guidance on establishing place-based arrangements are based on the principle of subsidiarity.

The Health and Care Act 2022 establishes new NHS bodies known as ICBs and requires the creation of ICPs in each local system area. This will empower local health and care leaders to join up planning and provision of services – both within the NHS and with local authorities – and help deliver more person-centred and preventative care.

Local authorities understand the needs and concerns of their local populations. They bring a wider perspective that extends beyond the NHS, and have the ability to act on social, economic and environmental factors that influence people’s health and wellbeing. Local authorities are core members of the systems and have a clear role in the ICP. As leaders of place, they will have an essential role with the NHS to plan and deliver integrated care services.

Additionally, the integration white paper sets out actions the government will take to support this greater collaboration at place level, and further develop the effective delivery of integrated health and care services.

It sets an expectation that places will make rapid progress in providing clarity on the governance and scope of their place-based arrangements to ensure NHS and local authority leadership are effectively bought together. This will include a single person, accountable for the delivery of shared outcomes and plans in each place, working with local partners.

Recognising the need for different approaches to meet the needs of different people, places will be able to decide which model of governance they adopt in line with the criteria. In some places, the single accountable person could – but does not need to be – a representative from the HWB. However, we expect all place-based arrangements to build on and work with existing forums such as HWBs as key existing place-based partnerships for driving integration.

This document therefore provides updated guidance on HWBs to align with the Health and Care Act 2022 and integration white paper, which we will engage further on before final publication.

Role and purpose of health and wellbeing boards

Decisions affecting planning, commissioning, operational co-ordination, and the use of resources in the health and care system will happen across a number of forums including ICPs and HWBs.

Each local authority (including London boroughs) is required to establish a HWB, which must consist of certain persons as set out in section 194 of the Health and Social Care Act 2012 including a representative from each relevant ICB.

The joint local health and wellbeing strategy (JLHWS) should directly inform the development of joint commissioning arrangements^{[footnote 1]} in the local area, and the co-ordination of NHS and local authority commissioning, including Better Care Fund plans.

HWBs remain a committee of the local authority, and provide a forum where political, clinical, professional and community leaders from across the care and health system come together to improve the health and wellbeing of their local population, and look to reduce health inequalities.^{[footnote 2]} Along with other leaders at place, it will continue to lead action to improve people’s lives at place level in many areas, and remain responsible for promoting greater integration and partnership between the NHS, public health and local government.

The functions of a local authority and its partner ICBs under sections 116 and 116A of the Local Government and Public Involvement in Health Act 2007 are to be exercised by the HWB established by the local authority.^{[footnote 3]}

In addition, HWBs can and do – at their discretion – invite other organisations to join the HWB, including, for example, organisations from:

• the voluntary, community and social enterprise (VCSE) sector
• children’s and adult social care
• healthcare providers

The HWB can therefore be the forum for discussions about strategic and operational co-ordination in the delivery of services already commissioned.

HWBs continue to be responsible for:

• assessing the health and wellbeing needs of the area and publishing a joint strategic needs assessment (JSNA)
• publishing a JLHWS that:
  • sets out the priorities for improving the health and wellbeing of its local population, and how the assessed needs will be addressed – including addressing health inequalities
  • reflects the evidence of the JSNA

The Health and Care Act 2022 has not fundamentally changed the required members of a HWB. The core statutory membership of an HWB is unchanged, other than requiring a representative from ICBs, rather than clinical commissioning groups (CCGs).^{[footnote 4]}

Each HWB also has a separate statutory duty^{[footnote 5]} to develop a pharmaceutical needs assessment (PNA) for their area for which a separate guidance is available. A PNA cannot be subsumed as part of a JSNA and JLHWS, but can be annexed to them.

Joint strategic needs assessments (JSNAs) and joint local health and wellbeing strategies (JLHWSs)

The statutory guidance explaining the duties and powers in relation to JSNAs and JLHWSs is unchanged. As part of our engagement, we will gather the information required to update this guidance.

JSNAs and JLHWSs are the vehicles for ensuring that the needs, and the local determinants of health of the local population are identified and agreed. The JSNA provides the evidence base for the health and wellbeing needs of the local population and should be kept up to date.^{[footnote 6]} The JLHWS sets out the agreed priorities and joint action for partners to address the health and wellbeing needs identified by the JSNA. They are not an end in themselves, but a regular process of strategic assessment and planning.

Local authorities and ICBs must have regard to the relevant JSNAs and JLHWSs so far as it is relevant when exercising their functions.

NHS England must also – in exercising any functions in arranging for the provision of health services in relation to the area of a responsible local authority – have regard to the relevant JSNAs and JLHWSs.

Joint strategic needs assessments (JSNAs)

In developing JSNAs, HWBs may consult any person it thinks appropriate. They should:

• look to involve the local community and representative organisations
• consider a broad range of issues across all demographics – this includes the:
  • needs of disadvantaged or vulnerable groups such as inclusion health^{[footnote 7]}
  • wider social, environmental and economic factors that might impact on health and wellbeing^{[footnote 8]}

JSNAs should also be informed by research, evidence, local insight and intelligence, as well as more detailed local needs assessments such as at a district or ward level.^{[footnote 9]} The integrated care strategy produced by the ICP will also be informed by research to ensure alignment. HWBs should also:

• consider where there is a lack of such evidence
• identify research needs in JSNAs that could be met by ICBs, local authorities and NHS England via the exercise of their research functions^{[footnote 10]}

Joint local health and wellbeing strategies (JLHWSs)

Joint health and wellbeing strategies have been known as joint local health and wellbeing strategies (JLHWSs) since 1 July 2022.

When the HWB receives an integrated care strategy from the ICP, they do not need to refresh JLHWSs if they consider that the existing JLHWS is sufficient.

The JLHWS sets out the vision, priorities and actions agreed by the HWB to:

• meet the needs identified within the JSNA
• improve the health, care and wellbeing of local communities, and reduce health inequalities.

HWBs will need to consider the integrated care strategies when preparing their own JLHWS to ensure that they are complementary. Conversely, HWBs should be active participants in the development of the integrated care strategy as guidance on the content of the integrated care strategy may also be useful for HWBs to consider in the development of their JLHWS.

The JLHWS is for the footprint of the local authority (with children’s and adult social care, and public health responsibilities). The integrated care strategy should build on and complement these place-based strategies, identifying where needs could be better addressed at the system footprint. It should also bring in learning from across the system to drive improvement and innovation.

The introduction of integrated care strategies is an opportunity for JSNAs and JLHWSs to be revised and/or refreshed to ensure that they remain effective tools for decision-making at both place and system levels. This includes maximising the opportunities of digitalising the JSNA and improving its accessibility for a range of users.

Examples of both JSNA and JLHWS development in practice can be found in the Local Government Association (LGA) document What a difference a place makes: the growing impact of health and wellbeing boards.

The relationship between HWBs and ICBs: continuity and change

As a minimum, we expect all partners – the HWBs, ICBs and ICPs – to adopt a set of principles in developing relationships, including:

• building from the bottom up
• following the principles of subsidiarity
• having clear governance
• ensuring that leadership is collaborative
• avoiding duplication of existing governance mechanisms

ICB and ICP leaders within local systems, informed by the people in their local communities, need to build on the work of HWBs. They should ensure that action at system-wide level adds value to the action at place level, so they are all aligned in understanding what is best for their population. In an effective health and care system, the ICP should build upon the existing work by HWBs and any other place-based partnership to integrate services.

Decisions should continue to be made as close as possible to local communities with decisions taken at a system level only where there is good reason to do so.^{[footnote 11]}

Working together at system level is helpful for issues that benefit from being tackled at scale. ICB and ICP strategies and priorities should not detract from or undermine the local collaboration at place. It is acknowledged that there is a wide diversity within ICB areas in terms of geography, population size and configuration of local authorities and NHS partners.

We therefore recognise that different approaches are required from one local population or area to another, and that there will be different levels of maturity and development.

The LGA has developed several case studies that highlight the ways in which HWBs are already working to improve planning, service delivery and outcomes for their local populations.

Continuity

The functions and duties that previously rested with CCGs have been conferred on ICBs – therefore, HWBs will continue the relationships and accountability they had with CCGs^{[footnote 12]} with ICBs.

This includes:

• forward plans (formerly commissioning plans)
• annual reports
• performance assessments

NHS England

In undertaking its annual performance assessment of an ICB, NHS England must include an assessment of how well the ICB has met the duty to have regard to the relevant JSNAs and JLHWSs within its footprint.

In conducting the performance assessment, NHS England must consult each relevant HWB as to its views on the ICB’s contribution to the delivery of any JLHWS to which it was required to have regard.

These duties are similar to how NHS England was required to assess CCGs previously.

Local authorities

Each local authority with statutory children’s and adult social care, and public health responsibilities has had a HWB in place since 1 April 2013, though many shadow boards were in operation before then.

District councils may create a HWB either as a subcommittee of a statutory HWB or as a local committee, though they are not required by statute to do so.

HWBs can decide to jointly carry out their functions with one or more other HWBs.

They may, for example, choose to set up a joint committee. Several local authorities have created joint HWBs across a wider footprint in order to address strategic priorities. Example case studies of these joint HWBs can be accessed through the LGA’s shared learning resources (see Case studies: Developing joint health and wellbeing board arrangements.

Pooled or aligned budgets

HWBs do not commission health services themselves, and do not have their own budget, but play an important role in informing the allocation of local resources. This includes responsibility for signing off the Better Care Fund plan for the local area and providing governance for the pooled fund that must be set up in every area.

Their role in joining up the health and care system, and driving integration will not be changed by the establishment of ICBs.

Changes to previous arrangements

This section sets out the changes that apply to both ICPs and ICBs together in relation to their relationship with HWBs, and also sets out the changes that impact each separately.

HWBs will now receive a copy of an ICB joint capital resource plan outlining their planned capital resource use. It is intended that, in sharing these with HWBs, there will be opportunity to align local priorities, and provide consistency with strategic aims and plans.

HWBs (and other place-based partnerships) will work with ICPs and ICBs to determine the integrated approach that will best deliver holistic and streamlined care and prevention activities, including action on wider determinants in their communities. ICPs will need to be aware of the work already being undertaken at place and build upon this. They should not seek to overrule or replace existing place-based plans.

JSNAs will be used by ICPs to develop their integrated care strategy, identifying where the assessed needs within the JSNA can be met by local authorities, ICBs or NHS England in exercising their functions.

The Health and Care Act 2022 requires an ICB and each responsible local authority whose area coincides with or falls wholly or partly within the board’s area to establish a joint committee for the board’s area (an ICP). The expectation is that all HWBs in an ICB area will be involved in the preparation of the integrated care strategy, but there is flexibility in how this happens in different areas. ICPs will need to ensure that there are mechanisms within their system to ensure collective input to their strategic priorities.

HWBs will now be required to consider revising their JLHWS following the development of the integrated care strategy for their area.^{[footnote 13]} If, having considered the integrated care strategy, HWBs consider their existing JLHWS to be sufficient, there is no requirement to refresh.

Care Quality Commission (CQC) reviews of integrated care systems will assess the provision of NHS care, public health and adult social care within the ICB area. They will consider:

• how well the ICBs, local authorities and CQC-registered providers discharge their functions in relation to the provision of care
• the functioning of the system as a whole, which will include the role of the ICP

The CQC is required to publish a report providing an independent assessment of the health and care in integrated care systems.

Integrated care boards (ICBs)

Every ICB that is within the HWB’s area will be represented on the HWB. It is important that the previous local knowledge, strategies and relationships developed by HWBs and CCGs are built upon in the new system.

ICBs will need to ensure that there is the right balance between system-level and place-level working. Further information on how HWBs and ICPs or ICBs will work together is available through the Must Know: Integrated health and care – how do you know your council is doing all it can to promote integration to improve health and social care outcomes at a time of change? LGA resource.

Each ICP will, as a minimum, be a statutory joint committee of an ICB and each responsible local authority within the ICB’s area. These members will be able to, at their discretion, appoint further members. We expect that, for ICPs to be effective, we will need to have a broader membership. These will build on existing partnership arrangements and actively support approaches where these are working well in line with the new legislation.

Health and Care Act 2022 – ICBs and HWBs

Joint forward plans

Before the start of each financial year, an ICB and its partner NHS trusts and NHS foundation trusts must prepare a joint forward plan.

ICBs must involve HWBs as follows:

• joint forward plans for the ICB and its partner NHS trusts and NHS foundation trusts must set out any steps that the ICB proposes to take to implement any JLHWS
• ICBs and its partner NHS trusts and NHS foundation trusts must involve each relevant HWB in preparing or revising their forward plans
• in particular, the HWB must be provided with a draft of the forward plan and consult with the ICB on whether the draft takes proper account of each relevant JLHWS
• following consultation, any HWB within the ICB’s area has the right to respond to the ICB and may give its opinion to NHS England
• within the ICB’s forward plan, it must include a statement from the HWB as to whether the JLHWS has been taken into proper account within the forward plan
• with the establishment of ICBs and the abolishment of CCGs, the former requirement for CCGs to share their commissioning plans with HWBs is now removed

These duties do not change how HWBs previously engaged with CCGs on their commissioning plans – the change is from CCG to ICB and commissioning plan to forward plan.

Annual reports

ICBs are required as part of their annual reports to review any steps they have taken to implement any JLHWS to which they are required to have regard. In preparing this review, the ICB must consult each relevant HWB.

These duties do not change how HWBs previously engaged with CCGs on their annual reports – the change is from CCG to ICB.

Joint capital resource use plans

ICBs and their partner NHS trusts and NHS foundation trusts are required to share their joint capital resource use plans and any revisions with each relevant HWB.

This is a new duty on an ICB not previously required of a CCG.

Integrated care partnerships (ICPs)

ICPs should identify priorities that can best be addressed at system level. HWBs will continue to provide leadership across place level. The relationship between an ICP and HWBs will vary depending on the number of HWBs in the system, their maturity and the existing partnership arrangements.

There are a small number of ICB areas that are coterminous with a single upper tier local authority. Since ICPs and HWBs have similar purposes, local authorities and ICBs may choose to bring their HWB and ICP together if many of the same parties are involved, and so it would be more efficient. This can be done by one part of the meeting formally being of the HWB and the other part of the ICP.

ICPs should use the insight and data held by HWBs around place in developing the integrated care strategy.

The integrated care strategy is intended to build on and not duplicate or supersede the JLHWS. The 5-year joint forward plan produced by the ICB must have regard to the integrated care strategy and must set out any steps on how the ICB proposes to implement any JLHWS that relates to the ICB area.

We expect HWBs and ICPs to work collaboratively in the preparation of the system-wide integrated care strategy that will tackle those challenges that are best dealt with at a system level – for example, workforce planning or data and intelligence sharing.

The integrated care strategy is for the whole population (covering all ages) and it must, among other requirements, consider whether their needs could be met more effectively by using integration arrangements under section 75 of the National Health Service Act 2006. When they receive integrated care strategy, HWBs must consider whether to revise the JLHWS. Alongside the JLHWS, the integrated care strategy should be the set direction for the system as a whole.

For ICPs, where there is just one joint local health and wellbeing board in their area, it is up to the HWB and ICP to determine how the 2 strategies will complement each other, and ensure that the assessed needs are addressed between them.

In many areas, place-based partnership arrangements go beyond strategic planning and include:

• shared leadership roles
• joint commissioning between local authorities and the NHS
• integrated service delivery by a range of providers

The new legislation is intended to give increased flexibility to systems to enable greater integration at place and system level.

Questions for engagement

We would like to engage with all sectors in the development of this guidance. Below we have included areas upon which we would welcome feedback:

• what examples can you provide of how HWBs are reacting to the introduction of ICBs or ICPs brought about by the Health and Care Act 2022?
• are there any issues you are encountering with the introduction of ICBs or ICPs that are affecting HWBs?
• are there new ways of working emerging that you would be happy to share as best practice?
• how are HWBs working to join up to ensure that they are part of discussions around implementation of the proposals in the integration white paper?
• we acknowledge the great work the LGA do in supporting HWBs and the resources they provide. In the final guidance we would like to provide examples in the form of diagrams and so on outlining the different structures and scenarios HWBs operate within, and would welcome examples or case studies
• does this guidance provide the information you need? Are there any gaps?

If you have feedback on this document, or want to be involved in the engagement process, please email integrationplacepartnerships@dhsc.gov.uk by 16 September 2022.

1. See section 75 of the National Health Service Act 2006. ↩

2. The LGA has revised their health and wellbeing system support offer to HWB chairs and other lead members, focussing on the implications for local government and the HWB of the ICSs. ↩

3. As stated in section 196(1) of the Health and Social Care Act 2012. ↩

4. CCGs are abolished with effect from 1 July 2022 and ICBs take on their commissioning functions. ↩

5. See section 128A of the National Health Service Act 2006, as amended by section 206 of the Health and Care Act 2012. See also regulations 3 to 9 and Schedule 1 of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013. ↩

6. See Best practice and opportunities for innovation in local JSNAs as developed by East Riding of Yorkshire Council. ↩

7. ‘Inclusion health’ is a ‘catch-all’ term used to describe people who are socially excluded, typically experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma), experience stigma and discrimination, and are not consistently accounted for in electronic records (such as healthcare databases). See Inclusion health: applying All Our Health. ↩

8. HWBs should consider groups who might be excluded from engagement, such as inclusion health groups, those who face other forms of social exclusion, transient populations, people at risk of homelessness, children and young people, or those who provide care to people in the HWB but live outside it. ↩

9. This should look at specific groups (such as those likely to have poor health outcomes – for example, care-experienced children and young people) and wider issues that affect health (such as housing or risk of homelessness, employment, education, crime, community safety, transport or planning). Evidence can be identified through public services data that identifies risk of homelessness and the Office for Health Improvement and Disparities’ inclusion health monitoring system, to be launched in 2023. ↩

10. ICBs and NHS England have duties in respect of research (sections 14Z40 of the Health and Care Act 2022 and 13L of the National Health Service Act 2006. ICBs, NHS England and local authorities have the power to conduct, commission or assist the conduct of research (paragraph 13 of schedule 1 of the National Health Service Act 2006). ↩

11. An example of how this works in practice can be accessed through West Yorkshire Health and Care Partnership. ↩

12. The Health and Care Act 2022 establishes new statutory NHS bodies known as ICBs, the successor body to CCGs. CCGs are abolished with effect from 1 July 2022. ↩

13. As stated in section 116B of the Local Government and Public Involvement in Health Act 2007. ↩