Questions by Dr Laura Kudrna. Dr Kudrna is a Research Fellow in Applied Psychology and theme lead on Wellbeing Economies for the Centre for Urban Wellbeing at the University of Birmingham.
Cross-posted on Applied Research Collaboration West Midlands News Blog.
I have seen several emails going around recently about the Birmingham Health and Wellbeing board. What is this board?
Health and Wellbeing boards were set up in England as part of the health and social care reforms in the mid-2010s. Each local authority in England has to set up a health and wellbeing board that is responsible for developing the health and wellbeing strategy for the local authority area. It has a list of partners it is supposed to engage with and a statutory set of members on the board. Beyond that, local authorities can add more people if they wish.
How are you involved in the Birmingham Health and Wellbeing Board?
I am there as a voluntary member. I was asked to be on the board because they were looking for someone from research and academia. I was asked first by Graeme Betts, Director of Adult Social Services, and met with the Cabinet Member for Health and Social Care – then I came on the board.
What is the Birmingham Health and Wellbeing Board Strategy?
One of the main tasks of the board is a joint strategic needs assessment of the health and wellbeing of their local area. This comes out of the fact that public health, which used to be part of the NHS, was transferred into local authorities. So, they have the duty for doing the overall health and wellbeing assessment of current and future needs, and from this, they develop a strategy that says, ‘these are the current priorities and needs we have identified in terms of health and wellbeing of our area – the city of Birmingham – therefore, we are going to put in place these actions to address gaps and make the most of opportunities’. It is a big strategy as you can imagine as it covers health and wellbeing for all ages and communities across the city of Birmingham.
“They have to develop a strategy that says, ‘these are the current priorities and needs we have identified in terms of health and wellbeing of our area – the city of Birmingham – therefore, we are going to put in place these actions to address gaps and make the most of opportunities’. It is a big strategy as you can imagine – health and wellbeing for all ages and communities across the city of Birmingham.”
Given it is such a big strategy, it sounds like it could be difficult to decide upon the priorities. How are these priorities decided upon?
It is a complicated and difficult task. There are two key individuals – Councillor Paulette Hamilton, Cabinet Member for Health and Social Care, and Doctor Justin Varney, Director of Public Health. These are the two people who decide how the board operates in practice. They engage with partners, including NHS providers, clinical commissioning groups, community and mental health trusts, broader council partners, patients, and people with lived experience. So the board has some agency to determine its own priorities – but it also engages with partners’ priorities. There is a complex interweaving of different responsibilities and strategic areas for health and wellbeing which come together. Sometimes the board leads, sometimes it responds. That makes it quite complicated being a board member.
What often happens is that there have been discussions over a long time, such as for end of life care, but board members may not have personally been involved in those discussions. I might be asked to comment on a strategy developed by a number of people over a considerable time period, for example – and it can be quite tricky to determine your individual influence as there is sometimes already consensus that this is already the best way to go among the main players. There are formal board meetings, which are publicly accessible, but underneath that there are also the broader partner discussions where decisions are made. That said, the chair is always open to comments and does recommend further work on proposals or a strategy if appropriate.
What, if anything, do you think could be done to improve upon that process of deciding priorities?
I think they do a good job of presenting a forward plan of what will be talked about, they get out quite extensive papers in advance, and have thought about key topics we are focussing on as a board and have set up a number of forums to take those forward. As a board member, I could take part in a forum such as on mental health, physical activity, or green and sustainable future for the city. Overall, I think the board does a good job given the scale of the task and the capacity of the board to respond to it. They are creative and give a number of different touch points and ‘deep dives’, such as learning more about people from certain communities, like the Afro-Caribbean community or those with visual impairments. You can be involved in the detail before it comes to the formal board meeting.
You mentioned the board focusses on certain priorities. What are some key priorities within the Birmingham Health and Wellbeing Board Strategy?
These include mental wellbeing, activity throughout the life course, healthy and affordable food, and, generally, the social determinants of health, which includes having a green and sustainable environment – both in terms of pollution, and also to encourage people to have physical activity outdoors and engage with others. There is also one on ‘protect and detect’ which is about infectious disease and the more technical public health elements. Alongside that they are also statutory responsibilities we have to do as a board – for example the Better Care Fund, which is an initiative the government introduced about pooling funding across integrated health and social care. We have a set of objectives that we have to meet to have this funding released and the health and wellbeing board has to sign it off because it is a government mandate. But the board’s strategy and general approach is more locally determined.
“It can be quite tricky to determine your individual influence. Sometimes the board approves or comments but actually, there is sometimes already consensus that this is already the best way to go among the main players. There are formal board meetings, which are publicly accessible, but underneath that there are also the broader partner discussions where decisions are made.”
With such a range of priorities, it sounds like an interdisciplinary approach might be needed to adequately inform and address them. As you may be aware the Centre for Urban wellbeing takes this approach, covering geographers, psychology, economics, humanities, and so on. Are you aware of the board drawing on interdisciplinary approaches?
You are correct – it has to be interdisciplinary. Right from the beginning the local authority has designed the board to have diverse perspectives. On the board you have clinicians, people with general practice backgrounds, community health backgrounds, police, social work and social care, voluntary sector, community sector and housing. In terms of the more academic side of it is there by default a mix of the practice disciplines and many people have dual roles in university and in practice. The interdisciplinary research bit is by default because they have the different practice sectors represented.
Alongside this, all the individual partners are engaging with researchers in terms of projects and strategies. There is something that could be done more formally considering the collective research contribution to the work of the board. There are individual projects people have contributed to, but I am not sure how we have thought through how we could get the most impact that we could – is there a way to make it easier for the board to get interdisciplinary perspectives from researchers to hear different opportunities? That is probably more a lack of foresight of us at universities than the board as such.
“It has to be interdisciplinary. Right from the beginning they have designed the board to have diverse perspectives. On the board you have clinicians, people with general practice backgrounds, community health backgrounds, police, occupational therapists and nurses, social work and social care, voluntary sector, community sector [But] is there a way to make it easier for the board to get interdisciplinary perspectives from researchers to hear different opportunities?”
Moving on now to wellbeing, in your opinion, how do you think ‘wellbeing’ is understood by the board?
Holistically – much more than about clinical healthcare, it is about the social determinants of health and thinking about how people live, what they do during the day, if they have employment, what kind of food they have access to, community relations, recognising those things determine wellbeing. The board is also keen on life course approach – recognising people have different opportunities and challenges in in younger, middle, and older ages, looking at different pressures and challenges at each age, but also looking across the life-course.
What about ‘place-based wellbeing’ or ‘urban wellbeing’?
It is very much a population-based approach and because it is in Birmingham it is urban by default – much of it at least. There is also a big focus in Birmingham on neighbourhood networks, drawing on community resources in particular neighbourhoods to promote wellbeing. There is also this idea of communities beyond physical geography – such as culture, sexuality, and end of life communities, drawing on common connections between people because of their circumstances and backgrounds. It is embedded in local communities and beyond.
In your opinion what do you view as key gaps in research on environments, health, and specifically the urban determinants of health?
The health and wellbeing board is aware that in some communities we need to do further research to understand how to promote their health and wellbeing. In terms of adult social care as a general sector we recognise some communities in the city have poorer outcomes than others, but I do not think we have done enough in adult social care as yet terms of properly understanding that. Moving beyond the fact we are highlighting that there are issues – such as mental health support or poverty in certain communities – we have not gone beyond to say, what are the nuances? How do we better develop the adult health and social care system to address sit in a meaningful way?
One of the big things now is strengths-based working, trying to build on people’s information networks and community resources rather than doing a statutory intervention. But those resources depend on the community they are from – whether it is Bangladeshi, Afro-Caribbean, Chinese, or another community. We probably do not understand that as well as we should, and we need to do more to understand communities better and those nuances. Some aspects may be stronger than the general community, others won’t be, and sometimes we won’t be facilitating the opportunities for them to do better.
It sounds like there is scope to better understand these communities.
Definitely. We did some work at the University of Birmingham for the Director of Adult Social Care in the West Midlands. This was an evidence review of what research there was – and there was not very much. That is not good enough is it – we need the evidence to add more insight to help policy and practice.
I am also wondering and how is the board thinking about health and wellbeing inequalities – why they exist and how to tackle them?
A huge question but an enormous focus. One of the top principles of the health and wellbeing board. It is a big part of the work of the health and wellbeing board, understanding how we can positively intervene across the life course. Whether it is to do with cultural diversity, mental health, sexuality, or a particular condition, that is all part of what the health and wellbeing board wants to do and promotes.
“One of the big things now is strengths-based working, trying to build on people’s information networks and community resources rather than doing a statutory intervention. But those resources depend on the community… some aspects may be stronger than the general community, others won’t be, and we need to do more to understand communities better and those nuances.”
How can other people become involved in shaping the work of the board?
First thing is to know about it – all the documents for the board, consultations, and forums is all available through the council website. Connect with that, see which areas you are interested in, and try to engage with the consultation and discussions that happen. I think the issue is more that people don’t realise it is there and put themselves forward, rather than a lack of opportunity.
Hopefully our conservation can inspire people to connect.
I hope so. That would be great, definitely.
What should I be asking you about that I haven’t?
One of the complexities of the board is that you have statutory responsibilities of councils to develop the strategy but alongside that you have an often parallel set of NHS developments. Sometimes these are correlated with the health and wellbeing board, but other times they can seem to overtake them. There has included over recent years sustainability and transformation partnerships, where the NHS was working across a bigger footprint than the health and wellbeing boards to determine what the sustainability of healthcare was. Then you get a point where the health and wellbeing board’s status gets reduced because the NHS says, ‘we are going to work together and sort out the issue’ – while they did interact, they can get overtaken by the latest health strategy.
Now, we have integrated care systems. There is recognition that the health and wellbeing boards need to connect with integrated care systems. We have this board – but how influential is it compared to NHS policies? It is not perfect, although it has a role, standing, and legal duty, sometimes the way stakeholders operate is they focus more on the NHS development than the local authority public health development. The environment, ecosystem, and organisational dynamics are important to remember.
What could be done to improve the interplay between NHS and local authority public health development – if you think could be done?
First, good communication and collaboration with senior people in the NHS and local authorities. Government also has a role in embedding health and wellbeing boards in the governance structure of health and social care. They are doing that in the new integrated care system – under the sustainability and transformation plan they did not really do it sufficiently – but they are now, which is good, but it is still to be seen what the balance of priority is – NHS boards? Or towards the more wider partnership board?
“It is still to be seen what the balance of priority is – NHS boards? Or towards the more wider partnership board?”
The other thing that is absolutely key – and that we could do more of in Birmingham – is the lived experience of individuals, families, and communities. There is an element of that, but we undoubtedly could do it stronger which holds us to account, to make sure we focus and prioritise what matters to people. The more opportunities we have to engage with people, support people, and work at a pace that enables people to contribute, the stronger the decisions and strategy will be. We have done work on it, but we certainly could do more of it I think.
“The more opportunities we have to engage with people, support people, and work at a pace that enables people to contribute, the stronger the decisions and strategy will be.”
A wonderful note to end on – the importance of involving communities and making sure the work is grounded in what matters for people’s lives. Thank you.