The white paper blueprint for major reform of the NHS crash-landed last week, at a time when health and social care are under strain as never before.
The goal is to ‘integrate decision-making at a local area’, said secretary of state for health and care Matt Hancock. But it has nothing substantial to say about the crisis in adult social care, and shadow health secretary Jonathan Ashworth questioned the timing, ‘in the middle of the biggest health crisis our NHS has ever faced’.
Timing aside, does it really deliver a complete reversal of the 2012 Act? Will it result in genuinely better, person-centred, health and social care? And will the reforms, in the words of Mr Hancock, ‘see different parts of the NHS joining up more seamlessly, and the NHS and local government working side-by side’? Will the plans, in his words, deal with ‘the inequalities that coronavirus has laid bare’?
Integration and innovation: working together to improve health and social care for all says the already embryonic integrated care systems (ICSs) - which were a key element of the 2019 NHS Long-term Plan – will be put on a statutory footing. The seven NHS England regions have 42 Sustainability and Transformation Partnerships (STPs), all at various stages of progression into ICSs.
Will statutory ICSs be coterminous with local authorities? The answer appears to be that places within an ICS will often, but not always, be coterminous with a council or borough. The white paper says: ‘Frequently, place level commissioning within an integrated care system will align geographically to a local authority boundary.’
Pledging to ‘removing the barriers that stop the system from being truly integrated’, it says ICSs will be responsible for supporting place-based joint working between the NHS, local government, community health services and other partners such as the voluntary and community sector.
What will the new system look like? ICSs will be made up of both an ICS Health and Care Partnership, bringing together the NHS, local government and partners, and an ICS NHS body. The ICS NHS body will be responsible for the day to day running of the ICS, while the ICS Health and Care Partnership ‘will bring together systems to support integration and develop a plan to address the systems’ health, public health and social care needs’.
Despite a shift in the landscape, the core of the Lansley reforms remains, as the BMJ has highlighted - with no duty on the Government to provide key services to everybody throughout England, and the basis for delivering services is still commercial contracts and the purchaser-provider split. In addition, the abolition of clinical commissioning groups (CCGs) – the clinically-led statutory bodies responsible for the planning and commissioning of health care services for their local areas - is implied rather than explicit.
NHS England and NHS Improvement/Monitor will merge, and there are two real reversals of the 2012 Act. Ministers will have more control over NHS England (NHSE), and competition rules will be abolished. The NHS have committed to consulting on the new regime. Where procurement processes can add value ‘they will continue, but that will be a decision that the NHS will be able to make for itself’.
The statutory ICS NHS body ‘will merge some of the functions currently being fulfilled by non-statutory STPs/ICSs.’ Each will have a unitary board directly accountable for NHS spend and performance within the system, with its chief executive becoming the Accounting Officer for the NHS money allocated to it.
‘As a minimum’ the board will include a chair, the CEO, and representatives from NHS trusts, general practice, and local authorities, ‘and others determined locally, for example community health services trusts and mental health trusts, and non-executives’. NHSE will publish further guidance on how boards should be constituted, including how chairs and representatives should be appointed.
But the ICS Health and Care Partnership, while ‘tasked with promoting partnership arrangements’, and promoting collaboration, ‘would not impose arrangements that are binding on either party, given this would cut across existing local authority and NHS accountabilities’. The white paper says the Government intends to bring forward separate proposals on social care reform ‘later this year’. Other key proposals of most relevance to local authorities include:
New emergency payments powers: Health secretary to make emergency payments directly to social care providers. But the power ‘will not be used to amend or replace the existing system of funding adult social care’ via local authorities.
Powers for the health secretary to require data from all registered adult social care providers.
Social care and health organisations to ‘share anonymised information’: There will also be a legal duty on NHS Digital ‘to have regard to the benefit to the health and social care system of sharing data that it holds when exercising its functions’.
The Care Quality Commission (CQC) will assess councils’ delivery of adult social care services: As a ‘final step’, the secretary of state to intervene where, following assessment, it is considered that a local authority is failing to meet their duties.
Better Care Fund: A new standalone legal basis for the Better Care Fund (BCF) The BCF was announced by the Government in the June 2013 spending round, requiring local government and the NHS to create a single pooled budget to incentivise shifting resources into social care and community services.
Public health: Alongside the closure of Public Health England and the creation of the National Institute for Health Protection, there will be a ‘range of targeted proposals in primary legislation relating to public health’. Taken together, the Government says these will ‘strengthen local public health systems, improve joint working on population health through ICSs, reinforce the role of local authorities as champions of health in local communities, strengthen the NHS’s public health responsibilities, strengthen the role of the Department of Health and Social Care in health improvement, and drive more joint working across government on prevention’. Specific legislation on obesity is promised.
Water fluoridation: The secretary of state will have the power to directly introduce, vary or terminate schemes. Central government will also become responsible for the associated work, including the cost of consultations, and capital and revenue costs of any new and existing schemes.
What do sector experts think about the broad direction of the plans? Former head of the King’s Fund thinktank Professor Sir Chris Ham told the BBC Radio World at One he welcomed what he characterised as a move towards enhanced collaboration rather than competition. He said that ‘if these changes work according to plan, then the difference for patients will be experiencing care that’s much more joined up’.
But on the way social care works with the NHS, he said the white paper ‘will not provide the solution that many of us having been arguing for on social care, because successive governments have ducked that’. He said the ‘tragic deaths in care homes [from coronavirus] were just one indication of why we need to look at a sustainable solution’.
In its response, the Local Government Association highlighted that action on social care reform is urgently needed. Indeed it is obvious that without the detail on social care reform, the white paper can only be the first step in the programme to deliver truly integrated systems.
While health and social care spokesperson for the County Councils Network (CCN) Cllr David Fothergill said there was ‘much to welcome in these proposed reforms’, he said any new performance and inspection regime ‘must be co-designed with local government’.
He added: ‘Local government must be an equal partner in ICSs and these bodies should be closely aligned to social care authorities’ boundaries to reduce complexity and enhance local collaboration.’
Cllr Fothergill said the white paper indicated that a ‘broader set of [social care] reforms will be set out later this year’, and that this wider approach to reform is ‘essential’. He said last week’s report from the CCN commissioned from Newton ‘proposes an optimised model of social care and shows what could be possible through well-integrated, locally-led services’. He concluded that this ‘must be underpinned by long-term funding for social care’.
Chief executive of the Social Care Institute for Excellence Kathryn Smith told The MJ her organisation was ‘generally supportive’ of the white paper proposals, ‘the main thing for me is about implementation….how we do that and who’s part of that – specifically the voice of the person accessing social care being involved, and not losing momentum for the wider social care reform that’s required’.
But she believes it ‘could have gone a little bit further and made it a duty to make sure that they include people drawing on care and support within this framework’.
She added: ‘When the white paper talks about co-production, it’s talking about co-production with other agencies and statutory bodies. I think that’s where we will push back in our response to the consultation - making sure ICSs have set up in their framework the process and ability to listen to people who actually use those services and live in those places.’
Speaking to The MJ, Adam Lent, chief executive of New Local said the establishment of ICSs ‘is no bad thing at all’, and offered an opportunity to get more integrated working, and a ‘more place-based strategic view’.
But he said the white paper did not have anything to say about organisations’ culture – and ‘makes the mistake of thinking that legal change, structure change, and process change is the key to driving greater impact’.
He added: ‘I’m not saying those things aren’t important. But if you don’t look at the organisational culture of the institution, then those sorts of changes are always going to be pretty limited in their impact. Whitehall makes this mistake over and over again, and they never learn.’
Calling the white paper ‘a massive missed opportunity’, he said the proposals ‘do not acknowledge and understand that there is real change happening in the public sector currently at the frontline’. This change centred on ‘working in a much more collaborative way with communities, and the whole community power agenda, which we work on very closely at New Local’. This was ‘spreading like wildfire in local government, and the pandemic has only accelerated that’.
He said that to have a white paper ‘that doesn’t even mention communities is absolutely ridiculous’.
What the white paper does not do, said Mr Lent, is to recognise ‘that you are not going to get rid of bureaucracy in the NHS just by setting up new governance structures and by playing around with the oversight of the NHS’.
He concluded that ‘integration had to be driven from the ground up’. While the white paper ‘won’t stop integration and will help a bit’, those he has spoken to ‘who are really involved with trying to drive integration will tell you that it happens on the frontline. It doesn’t happen in boardrooms of chief executives and senior directors coming together and saying how they are all going to collaborate’.
CIPFA’s health and social care policy manager Dr Eleanor Roy said the white paper was ‘a welcome step on the road to integration of health and care - particularly the recognition of local government as a fundamental partner, not only for their role in social care, but also public health and the wider determinants of population health and wellbeing’.
But ‘the devil will be in the detail’ she added – and concerns remain around some areas, ‘in particular the intention and operation of secretary of state powers’.
She added: ‘Proposals still lack clarity on fundamentally important issues such as the definition of ‘place’, recognition of the different tiers of local government and essential detail around finance and governance arrangements.
‘Whilst the aim is to increase collaboration and integration, the remaining uncertainty around planned reforms to both adult social care and public health mean that the picture remains incomplete.’
President of the Association of Directors of Public Health (ADPH) Dr Jeanelle de Grucy said that the proposals ‘recognise the strong collaboration already happening between directors of public health in local government and the NHS; and provide an opportunity to strengthen these relationships in future’.
While ICSs could develop ‘common agendas’, including ‘driving improvements in the underlying health and wellbeing of people and communities which councils champion’, success will ‘depend on the NHS and local councils being equal partners’.
She highlighted ‘limited focus in the white paper on the health inequalities that have been exposed and exacerbated by COVID-19’. She said what is now needed is a ‘renewed urgency to address these inequalities, which means valuing, funding and resourcing place-based public health leadership as a key part of reforms to the public health system’.
Vice chair of the ADPH and director of public health at Hertfordshire CC Jim McManus said this is a white paper that ‘is about NHS clinical care, while trying to be a paper about health improvement’.
While he said there was much in it to be welcomed, ‘this needs to be about outcomes, not about structures’.
He concluded: ‘If COVID has taught us anything, it should have taught us about the fact that social care is absolutely crucial in its own right to a functioning health system. The conversation almost needs to start with all the stuff that isn’t in there’. The phrase he comes back to is ‘you’re starting from the wrong place’.