The Government’s proposals for health and care integration in the White Paper ‘Joining up care for people, places and populations’ are focused on the development of place-based partnerships within new Integrated Care Systems (ICSs).
They will be widely welcomed by supporters of integration across the NHS and Local Government with specific proposals about the development of place-based shared outcomes to drive integration; joint leadership, accountability and finance; common digital and data systems; and integrated health and social care workforce planning.
What does integration really mean?
The White Paper gives a very clear definition of integration and is worth quoting in full:
“Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole. Everyone should receive the right care, in the right place, at the right time.”
The important point is that the scope of integration is not just about delivering better person-centred care, but also about improving the public’s health and reducing health inequalities. The paper, for example, calls upon people to ‘think housing and community’ when they develop their local partnerships and strategies. This White Paper represents a paradigm shift called for by, among many others, the Health Devolution Commission to move the NHS towards a fundamentally new purpose and a genuinely new partnership with Local Government, including social care and wider public services, the Voluntary Community and Social Enterprise sector, and the local people and communities that it serves.
There will be disappointment that there are no new resources identified specifically for delivering these proposals. But this White Paper should be viewed as re-baking the health and care cake rather than adding another layer of icing, that is, in broad terms, spending existing resources and using existing staff in a fundamentally new way not just describing a new service.
What new information has been shared?
There is plenty of valuable detail in the White Paper that will have a direct impact upon the work of a wide range of stakeholders in the new system and some highlights worth noting are:
Shared Outcomes: The development by local partners of new shared place-level outcomes – not inputs or outputs – will, as the paper says, be “a powerful means of bringing organisations together to deliver on a common purpose for the people they serve”. However, the extent to which there is flexibility for each place to set its own priorities for shared outcomes, as well as delivering national shared outcomes set by the Government, will indicate the degree of genuine devolution involved.
Governance: The White Paper outlines the design principles for place-level governance and describes how one model – a place board – would operate, but it also stresses that this is only one model. Local stakeholders will welcome this flexibility as it will allow them to determine their own structure that conforms to the design principles. It will be interesting to see how many place boards become chaired by elected representatives rather than professional leaders as a means of embedding local democratic accountability into the system.
Accountability: The creation of a new single officer accountable for the shared outcomes for each place or local area and a dual role across health and care will strengthen integrated leadership at place-level. This role will be accountable to the place board (or its equivalent), but it is important to note that the existing Accountable Officer duties within local Authorities and the Integrated Care Board (ICB) CEO will not change, so the relationship between these roles and their different accountabilities will be important.
Pooled Budgets: There is an expectation that a place-based approach will increasingly adopt pooled budgets that are more formal than simply aligning budgets. This is welcome but the key challenge for many will be reaching an agreement among local partners about what amounts to a ‘fair and appropriate’ contribution to any pooled budget.
Leadership: Without, pre-empting the current Health and Social Care Leadership Review, the paper spells out what local health and social care leaders should do in their areas to support place-based integration. It is an interesting list of tasks, one of which is to listen to the voices of people who draw on services when designing those services – an activity perhaps where health leaders might draw on the experience of social care leaders for whom this is fundamental to their purpose.
Digital: These proposals are welcome; however, local health and social care providers will be expected to reach a minimum level of digital maturity and be connected to a shared care record as part of place-based working. This will be a big challenge for the social care sector where 60% still use paper-based care records, and significant funding will be required to achieve this goal.
Workforce: The proposals are a major step forward in thinking towards a more integrated approach to the workforce planning across health and social care. The description of what an integrated workforce means in practice will provide a helpful measure of the outcomes that an ICS health and care workforce strategy and plan should be seeking to achieve. There will be a concern however that the proposed review of regulatory or statutory requirements to remove barriers to workforce integration could undermine hard-won pay and conditions in the NHS, without lifting the wholly inadequate pay and conditions of hundreds of thousands of care workers in the social care system.
A leap forward
There is a great deal in this White Paper to be welcomed. And, inevitably, there remains some major unanswered questions – where, for example do the proposals to establish large scale provider collaboratives fit with place boards? How will large acute trusts be integrated into place-level strategies? And how will Primary Care Networks relate to place-level partnerships?
The conclusion though is positive. This White Paper sets out in clear and, in the most part, unambiguous terms, what the NHS and Local Government must now do to shift our health care system away from a traditionally NHS-dominated, treatment-centred approach, to an accountable partnership of local organisations with a common purpose focused on delivering seamless person-centred care, improving the public’s health and reducing health inequalities. One small white paper step for Government, potentially one giant leap forward for the nation’s health and wellbeing.
by Phil Hope, former Health Minister and Strategic Adviser to GK Strategy