The Health and Wellbeing Board (HWBB) in Birmingham brings together strategic management of health and care with democratic representation to address health inequalities in a population of over 1 million that is diverse and generally sicker than average. Early experiences found value in closer community links but challenges include integrating services, managing risks, and balancing representation with effective decision-making. Key priorities are appointing a Director of Public Health, overseeing public health transitions, and establishing clear criteria for assessing joint commissioning and service integration across age groups.