The principle behind the creation of health and wellbeing boards (HWBs) was one of the few elements of the Health and Social Care Act that was widely backed by healthcare professionals.
Shifting public health over to local authorities and sharing the responsibility between clinical commissioners and elected members was seen by many as the right step forward.
Yet as April approaches, many GPs are beginning to grow fearful about just how much power HWBs will have over clinical commissioners. John Wilderspin, former national director of HWB implementation at the DH, wrote in The Guardian newspaper last month that it was clear the boards were becoming 'the system leaders' in the new health, social care and local government environment.
If Labour wins the next general election, it plans to formalise this by downgrading CCGs to an advisory role supporting the boards (GP, 4 February).
But for now, Dr Charles Alessi, chairman of the National Association of Primary Care (NAPC), denies that CCGs will be subservient to HWBs.
'It's about having a system of checks and balances. Boards are there to ensure that proposed commissioning plans reflect the needs of the population, because they will have a patient voice and elected politicians on the board.
'But CCGs are where the real action will be centred. I don't really see any difficulty in the two being able to work together very peaceably.'
|What is a health and wellbeing board?|
Two distinct types of HWB are forming, according to Lorna Shaw, senior adviser to the Local Government Association health and wellbeing board leadership programme. One is characterised by a large board with many stakeholders, including providers and voluntary sector organisations. Many of these boards see their role as providing the momentum for large-scale change and as 'influencers' of commissioning.
However, the danger for such boards is that they could descend into talking shops, where very little is actually achieved. Many HWBs are forming 'task and finish' sub-groups to counteract this.
The second form of HWB is a much smaller, leaner board, usually made up of just the minimum required membership. These boards see their role as commissioning in partnership with CCGs.
Although this model promotes swift decision-making and encourages better understanding of different roles, the fear is that such boards will be seen as closed shops.
This raises questions about who has access to the board, whose voices are heard and which services are commissioned.
Dr Rosie Benneyworth, urgent care and cancer commissioning lead for Somerset CCG, is also a vice-chairwoman of Somerset HWB.
She admits they are in a fortunate position, with good historical relationships with the local council and only one CCG for the area.
'We are looking at how we can best use the HWB for a collaborative approach to commissioning,' she says.
The CCG feeds information to the HWB to allow early input to decision-making, and key council and CCG staff are represented on the board.
Dr Benneyworth says the approach has helped cut duplication of work through a more collaborative approach to reablement services, which aim to help patients regain their independence.
'Now we have joint teams meeting patients' needs much better and we feel this is an example of how we can work together to help everyone's budgets,' she says.
GPC deputy chairman Dr Richard Vautrey sees funding as one of the biggest challenges facing HWBs and GPs - both clinical commissioners and providers. Local enhanced services (LESs) are at greatest risk, particularly for public health services such as smoking cessation and sexual health clinics.
'GPs are very concerned that LES money will simply be absorbed by councils plugging their own massive funding gaps,' he says.
For Manchester GP Dr Siobhan Macintyre, who runs a sexual health screening service, LES cuts could mean losing a full-time nurse and a doctor. 'We've invested heavily in sexual health screening and worked closely with the GUM clinic to make sure we have a high level of skills here,' she says.
However, Dr Macintyre fears a Manchester City Council review will move sexual health services and screening to a hospital GUM clinic. 'It's ridiculous because it goes against the current trend to move services into the community and increase patient choice,' she says.
Dr Alessi says GPs should accept that they may lose funding for some services if there is a more efficient and better way of providing public health.
'We need to be providing services as imaginatively as we can. Sexual health is one of those areas that cuts across almost all sectors and is just one of the issues we are going to be faced with in this tight fiscal environment. CCGs are not there to reflect the needs of practices, but the needs of the population,' he says.
Seamus Breen, assistant director of health reform and development at North Yorkshire Council, agrees the tight financial environment will force creative thinking.
'We have in the past too often thought of acute and primary care in terms of bricks and mortar, that is, hospitals and GP surgeries. But with telehealth and telemedicine, the boundaries are becoming blurred. We need to think about meeting needs and asking, does care have to be delivered in a hospital or could it be delivered closer to home?'
Ms Shaw says in the face of potentially unpopular decisions, CCGs and councils should look on HWBs as their greatest strength.
'GPs need to realise that local members are often much better able to take local communities with them on the path of change than perhaps some clinicians are able to. In return, GPs can provide the clinical evidence base for decisions.'