Guidance

Health and wellbeing boards – guidance

Published 22 November 2022

Applies to England

Purpose of this guidance

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.

The Health and Care Act 2022 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 statutory role in instilling mechanisms for joint working across health and care organisations and setting strategic direction to improve the health and wellbeing of people locally.

This non-statutory guidance sets out the roles and duties of HWBs and clarifies their purpose within the new system architecture. It accompanies previously published statutory guidance on joint strategic needs assessments (JSNAs) and joint local health and wellbeing strategies (JLHWSs). The Health and Care Act 2022 amends section 116A of the Local Government and Public Involvement in Health Act 2007, renaming ‘joint health and wellbeing strategies’ to ‘joint local health and wellbeing strategies’. Statutory guidance on JSNAs and JLHWSs currently remains unchanged.

This guidance should support ICB and ICP leaders, local authorities and HWBs to understand how they should work together to ensure effective system and place-based working, following the principle of subsidiarity.

We acknowledge 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 to another, one area to another, and that there will be different levels of maturity and development. Throughout this guidance, we have included illustrative examples of these different approaches.

Background and context

Promoting integrated, person-centred care and health improvement 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)

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.

HWBs:

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

The Health and Care Act 2022 did not change the statutory duties of HWBs as set out by the 2012 Act but established new NHS bodies known as ICBs and required 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.

The integration white paper set out opportunities to enable greater collaboration at place level to facilitate the effective delivery of integrated health and care services. We expect all place-based arrangements to build on and work with existing forums such as HWBs as key existing place-based forums for driving integration.

This document therefore provides guidance on HWBs to align with the Health and Care Act 2022 and wider place-based strategy. It replaces draft guidance published by the Department of Health and Social Care in July 2022.

Role and purpose of health and wellbeing boards

HWBs remain a formal statutory committee of the local authority, and will continue to provide a forum where political, clinical, professional and community leaders from across the health and care system come together to improve the health and wellbeing of their local population and reduce health inequalities. The Local Government Association (LGA) has revised its support offer to HWB chairs and other lead members focusing on the implications of integrated care systems. The LGA has also developed several case studies that highlight the ways in which HWBs have been working to improve planning, service delivery and outcomes for their local populations. The government has also published guidance on place-based approaches to reducing health inequalities.

Along with the HWB’s other statutory functions, 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 1]}

Following the Health and Care Act 2022, clinical commissioning groups (CCGs) are abolished with effect from 1 July 2022 and ICBs take on their commissioning functions. The core statutory membership of HWBs is unchanged other than requiring a representative from ICBs, rather than CCGs. HWBs can continue, at their discretion, to invite other organisations to join the HWB including, for example:

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

Case study: County Durham

Supplementary representation on the County Durham HWB membership, identified as part of its regular governance review, includes County Durham and Darlington Fire and Rescue Service, the Office of the Police and Crime Commissioner, and Housing representation. This is to ensure the health and care needs of residents are identified and addressed as part of the wider system.

Case study: Redbridge

In addition to its statutory membership, Redbridge HWB has lay members, housing reps, police and fire service, acute and community health providers and voluntary sector to provide a much more holistic leadership in supporting the wider determinants of health.

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

HWBs should review their membership following the establishment of ICBs and ICPs and their associated functions and duties. Any changes should reflect local circumstances and priorities and continue to meet the statutory requirements.

In the few areas where the ICP and HWB are coterminous (cover the same geographical boundaries), it may be appropriate for the HWB and ICP to have the same members. This can be done, for example, by one part of the meeting formally being of the HWB, and the other part of the ICP. However, both have different statutory functions which each will be required to fulfil.

Case study: Derbyshire

Derbyshire County Council’s HWB reviewed its membership following the establishment of the Derby and Derbyshire ICP. All district and borough councils within Derbyshire now have elected members represented on the HWB. Previously this was just 2 representatives.

Extending the membership to include district and borough councils provides the HWB with a distinct role from the new ICP structures, but also enables a stronger place focus and recognises the importance of district and borough councils in prevention and promoting wellbeing.

Derbyshire HWB used examples of cross cutting issues such as housing to consider how the new ICP/ ICB structures work alongside the HWB and other existing groups and organisations.

Case study: Lincolnshire

Lincolnshire is a coterminous system. The HWB and ICP cover the same geographical area. The membership of the ICP mirrors the HWB and is reviewed annually to ensure as much alignment as possible. Times, locations and frequency of ICP meetings are aligned with those of the HWB.

Case study: Somerset

Given they cover the same geographical area, it has been proposed that the Somerset HWB and the Somerset ICP are aligned as committees in common.

From April 2023, it is proposed that the Somerset board will be established as the single high-level strategic partnership board for the county. This will consist of both the ICP and HWB. If required to fulfil the statutory duties of either board, it is proposed the Somerset board will split the agenda and show distinct agenda items for each board.

In order to operate in this way, it is important that the membership of the Somerset board encompasses the membership of both the health and wellbeing board and the ICP.

Case study: North Yorkshire

North Yorkshire HWB reviewed its membership to reflect the introduction of ICPs. Humber and North Yorkshire ICP is represented on the HWB by its chief operating officer – who is also the vice chair of the HWB – and the place director for North Yorkshire. West Yorkshire (which covers about 10% of North Yorkshire) is represented by the chief operating officer, Bradford District and Craven Health and Care Partnership.

Along with other local leaders, HWBs will continue to lead action at place level to improve people’s lives and remain responsible for promoting greater integration and partnership between the NHS, public health and local government. This involves working effectively with local leaders, including place-based partnerships. Adopted ways of working should reflect local priorities and circumstances. Different partners may have different geographical footprints and governance structures and should therefore work together and ensure there is clarity on their respective roles. How HWBs work with place-based partnerships will vary, but HWBs can and should have an important role.

Case study: Bath and North East Somerset

It has been agreed that the Bath and North East Somerset HWB will set the vision for desired population outcomes for Bath and North East Somerset, the strategic direction and high-level priorities for system partners including the Integrated Care Alliance (ICA) and the Sustainable Places Board. Relevant priorities in the joint health and wellbeing strategy will be implemented through the ICA workplan.

Case study: Bedford

Place arrangements for Bedford Borough have placed great emphasis on partnership working, including the HWB as the strategic lead for place. A partnership arrangement including delivery groups at senior officer level report to the HWB on the delivery of place priorities as well as those in the joint local health and wellbeing strategy.

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

HWBs continue to be responsible for:

• assessing the health and wellbeing needs of their population and publishing a joint strategic needs assessment (JSNA)
• publishing a joint local health and wellbeing strategy (JLHWS), which sets out the priorities for improving the health and wellbeing of its local population and how the identified needs will be addressed, including addressing health inequalities, and which reflects the evidence of the JSNA
• The JLHWS should directly inform the development of joint commissioning arrangements (see section 75 of the National Health Service Act 2006) in the place and the co-ordination of NHS and local authority commissioning, including Better Care Fund plans

Each HWB also has a separate statutory duty^{[footnote 2]} to develop a pharmaceutical needs assessment (PNA) for their area, for which separate guidance is available (see Pharmaceutical needs assessments: information pack). A PNA cannot be subsumed as part of JSNA and JLHWS but can be annexed to them.

The statutory guidance explaining the duties and powers in relation to JSNAs and JLHWSs currently remains unchanged.

JSNAs and JLHWSs are the vehicles for ensuring that the needs and the local determinants of the 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 regularly. 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 they are relevant when exercising their functions. NHS England must have regard to the relevant JSNAs and JLHWSs so far as relevant, in exercising any functions in arranging for the provision of health services in relation to the geographical area of a responsible local authority.

Joint strategic needs assessments (JSNAs)

In developing JSNAs, we expect HWBs to engage with any person, group or organisation agreed appropriate. They should involve the local community, representative organisations and consider wider social, environmental and economic factors which might impact on health and wellbeing across all demographics. HWBs should consider groups that 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, babies, children and young people, and unpaid carers, including those who provide care to people in the HWB place but live outside it. Inclusion health is a 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.

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. 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 (OHID) inclusion health monitoring system, to be launched in 2023. 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 and identify research needs in JSNAs that could be met by ICBs, local authorities and NHS England via the exercise of their research functions. ^{[footnote 3]}

Joint local health and wellbeing strategies (JLHWSs)

The JLHWS sets out the vision, priorities and action agreed by the HWB to meet the needs identified within the JSNA and to improve the health, care and wellbeing of local communities and reduce health inequalities. The JLHWS is for the footprint of the local authority (with children’s and adult social care and public health responsibilities).

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

When the HWB receives an integrated care strategy from the ICP, it does not need to refresh JLHWS if it considers that the existing JLHWS is sufficient.

The integrated care strategy should build on and complement JLHWSs, identifying where needs could be better addressed at the system level. It should also bring 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, for example through easy-read formats.

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 relationship between health and wellbeing boards and integrated care systems: 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, with clarity at all times on which statutory duties are being discharged
• ensuring that leadership is collaborative
• avoiding duplication of existing governance mechanisms
• being led by a focus on population health and health inequalities

ICB and ICP leaders within local systems, informed by the people in their local communities, need to have regard for and build on the work of HWBs to maximise the value of place based collaboration and integration, and reduce the risk of duplication. They should ensure that action at system-wide level adds value to the action at place level, and they are all aligned in understanding what is best for their population. ICB and ICP strategies and priorities should not detract from or undermine the local collaboration at place level. In an effective health and care system the ICP should build upon the existing work by HWBs and any place-based partnerships to integrate services. Working together at system level is helpful for issues that benefit from being tackled at scale.

Following the principle of subsidiarity, apart from those which are often best approached at system level (for example, workforce planning, or data and intelligence sharing), decisions should continue to be made as close as possible to local communities. Examples of how this works in practice can be accessed through the following resources: West Yorkshire Health and Care Partnership and Effective working across neighbourhood, place and system.

Continuity

HWBs and 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. Case studies of these joint HWBs as an example can be accessed through this LGA resource (see Case studies: Developing joint health and wellbeing board arrangements).

HWBs and pooled and 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. Executives with lead responsibility for commissioning or operational delivery at place may continue to come together as members of the HWB, supporting integration.

HWBs and ICBs

HWBs will continue the relationships they had with CCGs with ICBs. This includes:

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

Joint forward plans (replacing commissioning plans)

Before the start of each financial year, an ICB, with its partner NHS trusts and NHS foundation trusts, must prepare a 5-year joint forward plan, to be refreshed each year.

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 their 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 the ICB must consult with the HWB 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 proper account of 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

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.

Performance assessments

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

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 (and other place-based partnerships) will work with ICPs and ICBs to determine the integrated approach that will best deliver holistic care and prevention activities, including action on wider determinants in their communities.

The Care Quality Commission’s (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, as well as 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.

HWBs and ICBs

Every ICB which is within the HWB’s footprint 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/ICBs will work together is available through the ‘Must Know’ LGA resource: 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?

Joint capital resource use plans

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

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

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 ICPs

Each ICP will, as a minimum, be a statutory joint committee of an ICB and each responsible local authority within the ICB’s area. The ICP can appoint any other members as it sees fit. We expect that for ICPs to be effective, they will need to have a broad membership. These should build on existing partnership arrangements.

As outlined previously, where the HWB and ICP are coterminous (cover the same geographical boundaries), it may be appropriate to bring the HWB and ICP together, although each will need to fulfil its own statutory functions. 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.

ICPs should use the insight and data held by HWBs in developing the integrated care strategy. JSNAs will be used by ICPs to develop the 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 5-year joint forward plan, produced by the ICB and its partner NHS trusts or NHS foundation trusts, must set out any steps on how the ICB proposes to implement any JLHWS that relates to the ICB area, and the ICB must have regard to the integrated care strategy when exercising any of its functions.

We expect HWBs and ICPs to work collaboratively and iteratively 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 expectation is that all HWBs in an ICB area will be involved in the preparation of the integrated care strategy. There is flexibility in how this will happen in different areas. ICPs will need to ensure that there are mechanisms within their system to ensure collective input to their strategic priorities, and that sufficient time is provided for this.

Case study: Berkshire West

Berkshire West comprises 3 unitary authorities, each with their own HWB. The 3 health and wellbeing boards have worked together to prepare a single joint local health and wellbeing strategy across the 3 areas, albeit with a separate delivery plan for each area. This will make it easier for the ICP when preparing its integrated care strategy.

The integrated care strategy is for the whole population (covering all ages), and it must, amongst other requirements, consider whether their needs could be met more effectively by using integration arrangements under section 75 of the NHS Act 2006. HWBs will now be required to consider revising their JLHWS following the development of the integrated care strategy for their area (Local Government Act 2007), but are not required to make changes. Alongside the JLHWS, the integrated care strategy should set the direction for the system as a whole.

For ICPs, where there is just one HWB 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.

1. Section 196(1) of the Health and Social Care Act 2012. ↩

2. Section 128A of the NHS Act 2006, as amended by Section 206 of the Health and Care Act 2012. See also Regulations 3 - 9 and Schedule 1 to the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (S.I. 2013/349). ↩

3. ICBs and NHS England have duties in respect of research (sections 14Z40 and 13L, respectively, of the NHS 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 NHS Act 2006). ↩