LGA response to Health and social care integration: joining up care for people, places and populations

• The LGA is the national member body for local authorities and we work on behalf of our member councils to support, promote and improve local government.
• The key messages and the responses to specific questions in the white paper, are drawn from the views of the LGA Executive Advisory Board, the Lead Members of the LGA Community Wellbeing Board, discussions at a number of regional meetings for local government officers and elected members, and a small number of responses from individual local authorities.
• We trust that you find this response helpful in identifying the next steps for integration. We are committed to working with Government and other key national partners to significantly escalate the scale and pace of integration for the benefit of people who draw on care and support, and for improved health and well-being outcomes for our communities.

• The LGA welcomes the values underpinning the white paper, and its ambition and scope which puts people and communities at the centre of integration policy to ensure that everyone gets the right care in the right place at the right time to achieve better health outcomes. We welcome the recognition in the white paper that this is the primary purpose of integration.
• Achieving the scale of ambition set out in the White Paper will require substantial and long-term commitment not only from Government but from local government and NHS leaders at every level – national, regional, system, place and neighbourhood. We look forward to seeing this reflected as the ICS and wider reforms are rolled out in practice. Leaders at every level will need support to remain focused on achieving the best outcomes for their populations. The LGA are committed to working with national partners to provide sector-led support so that all areas achieve their ambitions for better health outcomes.
• The reform agenda for health, social care, population health and integrated care is extensive and complex, including the Health and Care Bill (subject to Parliamentary passage), People at the heart of care: adult social care white paper; the Integrated Care System Design Framework, the Messenger review of health and social care leadership, the Fuller stocktake of primary care, the Levelling-up white paper and forthcoming key policy documents, including the refresh of the NHS Long-Term Plan, the health disparities white paper, the Special Educational Needs and Disabilities Green Paper and the review of children’s social care. It is crucial that Government ensure that the various national policy strands are joined up and consistent.
• We welcome the focus on prevention, but intent and ambition needs to be matched with adequate investment. Councils’ public health grant has been cut by 24 per cent on a real-terms per capita basis since 2015/16. In our Spending Review submission, we called for £1 billion of funding in 2022/23 rising to £3 billion in 2024/25 for a new Community Investment Fund, with much of the funding potentially directed through the voluntary and community sector.
• The Better Care Fund (BCF), which is cited in the white paper as a key driver of integration, has seen a financial uplift only for the NHS elements. Other important components of BCF funding, the improved Better Care Fund and the Disabled Facilities Grant, have not been increased.
• The emphasis on prevention will, necessarily, require a focus on the health and wellbeing of children and young people to give them the best possible start in life and enable them remain health and independent throughout life. We are disappointed, therefore, with the lack of consideration of the health and wellbeing of children and young people in the white paper. We urge Government to state clearly that children and young people’s health and wellbeing is essential to the preventative approach at the core of the white paper.
• The white paper sets out a clear expectation of close collaborative and inclusive working between ICSs and places, in which systems and places, and the NHS and local government have parity. The focus on place is a welcome counterbalance to the recent focus on the role of ICSs.
• We support proposals for a simplified unified national outcomes framework for integration, which allows place and system leaders to identify their own priorities. We also welcome the expectation that all places will work collaboratively, including people who draw on care and support, to develop shared priorities and drive forward action to achieve them. But it is not clear from the white paper whether the proposed single outcomes framework will replace or be additional to the existing outcome frameworks for the NHS, adult social care, public health, and children and young people. We strongly urge Government to develop a single shared outcomes framework to replace the existing ones. This will ensure that all key partners are focused on meeting a small set of shared national outcome targets. It is also imperative that the outcomes framework looks to the medium and long term across the whole health and care system, and not be focused on short-term or immediate outcomes for only a section of the system.
• There is a real opportunity for the shared outcome framework to include a focus on the fourth objective of the NHS Long Term Plan – identifying the socio-economic contribution of the NHS. This will also link the shared outcomes framework with the 12 Missions of the Levelling-up Framework, in particular the missions relating to education, employment, increasing healthy life expectancy and reducing health inequalities.
• Shared place outcome plans should build on and enhance existing place-based plans to improve services and population health outcomes. Place-based health and wellbeing boards already have key statutory duties to develop joint strategic needs assessments and joint health and wellbeing strategies. In areas where the HWB and the ICS share a footprint, there is a strong case for the existing joint health and wellbeing strategy to be revised and refreshed to form the shared outcomes plan, especially as many joint health and wellbeing strategies have been co-produced with citizens and people with experience of health and care services.
• With regard to a single accountable officer, local government and the NHS will need to jointly agree arrangements based on what is locally appropriate. In many places, they may wish to consider joint appointments to this role. There is a diversity of view on this proposal among local authorities. Some question whether a single individual can be held accountable for all the plans and services that contribute to better health and care outcomes, in particular the wider determinants of health including housing, skills, economic prosperity etc. We applaud the good intent of joint posts to lead integration, but lines of accountability are complex and developing integration leaders in all parts of the system should be a priority. While ultimate accountability for the delivery of statutory responsibilities for budgets will remain with the organisations that pool or align funds and agree joint plans, it is possible that a single person could lead and manage the delivery of joint plans.
• Many existing organisations, plans and partnerships – health and wellbeing boards, joint strategic needs assessments, joint health and wellbeing strategies, voluntary and community groups - are organised on the basis of local authority boundaries. In determining place boundaries, therefore, ICSs should build on the boundaries of councils that have health and wellbeing boards, rather than creating new footprints that do not align with existing arrangements, unless there is local agreement to do otherwise. Coterminosity will make it easier for place-based partners to develop shared priorities and shared action.
• We welcome the white paper’s holistic approach to care and support, for example recognising the role of housing in supporting people to maintain healthy independent living. However, given the focus on the role of housing in the adult social care white paper, it is disappointing that there are relatively few references to housing as key component of integrated care and support in the integration white paper.
• The proposals for strengthening the levers of integration – leadership and accountability, financial frameworks, digital technology and data sharing, and workforce planning and development – are ambitious and will require major investment and support from national partners. If this is done well, there is a real opportunity to improve local authority, NHS and other care and support services. But if there is inadequate investment and commitment, there is a risk of creating confused accountability and wasteful bureaucracy. The LGA will continue to work closely with Government to support place leaders to drive the integration agenda. We will also work with Government to identify the resources and support needed to embed effective integration at place, and for joint working between place and system.
• The LGA is working with the CQC and other stakeholders to develop the oversight and assurance framework for ICSs, as well as the assurance framework for adult social care. We will continue to make the case that ICSs will need to demonstrate, not only that they work collaboratively and inclusively with place based leaders, that they also operate on the principle of subsidiarity to ensure that decisions are taken at the most local level appropriate. With two parallel assurance processes in development, it is important that the right links are made between the two, including consideration of how the functioning of one may impact the other.

Shared outcomes

• Are there examples where shared outcomes have successfully created or strengthened common purpose between partners within a place or system?
  
  There are already numerous examples of the political, professional, clinical and community leadership working at place and system levels on shared objectives. Just some examples include the shared priorities of the Greater Manchester Health and Social Care Partnership, the place-based approach of the West Yorkshire and Harrogate ICS, the Wigan Deal and Bristol One City Plan, which brings together a wide range of public, private and third sector partners with a shared vision of making Bristol a fair, healthy and sustainable city where everyone can share its success by 2050. We are keen to work with the Government and other national partners to build a resource library of case studies for all local government, NHS and other stakeholders to learn from existing good practice.
• How can we get the balance right between local and national in setting outcomes and priorities?
  
  The proposed single outcomes framework will help the NHS and local government to focus on common national outcomes and priorities. But key to getting the balance is minimising national targets to allow local places and systems to focus on a few critical priorities that will have most impact on improving care and support and improving outcomes. A common theme with the examples given in the question above, is that each is underpinned by local discussion and agreement, ensuring that each priority matters to citizens and local organisations.
• How can we most effectively balance the need for information about progress with a focus on achieving outcomes?
  
  Identify a few reliable proxy progress indicators and allow sufficient time for places to make progress, recognising that they vary in terms of their current journey to integration.  Allow local areas to set their own baselines so that progress expected is realistic. Many HWBs already have their own monitoring dashboards which use proxy indicators to monitor progress on the outcomes of the joint health and wellbeing strategy. 
  
  
  
  It is important that Government minimise reporting requirements to enable areas to get on with the job, and encourage them to develop their own dashboards so that they can take responsibility for their own progress. It is likely that most if not all outcomes selected will already be collected elsewhere, therefore meeting the requirement for information. The key to a local outcomes framework is how local leaders use it to drive local progress.
• How should outcomes be best articulated to encourage closer working between the NHS and local government?
  
  Shared outcomes should be expressed in terms of health and wellbeing outcomes for individuals and communities, rather than clinical or process outcomes. Many local partnerships already use ‘I’ statements developed by National Voices to ensure that they remain focused on making a difference to individuals’ experience of care and support.
  
  
  
  In terms of population health outcomes, in almost all areas there is a strong existing evidence base –  the joint strategic needs assessment and the joint health and wellbeing strategy -  on which to build. A recent LGA survey on HWBs  found that 85 per cent of HWBs had either recently refreshed their JSNA or were currently doing so to reflect the changed population health needs as a result of Covid, or in response to the development of ICSs.  Shared outcome plans can draw on the evidence base in the JSNA.
• How can partners most effectively balance shared goals or outcomes with those that are specific to one or the other partner?
  
  They should focus on the shared outcomes expressed in the HWB joint health and wellbeing strategy at place, and the ICP integrated care strategy at system since these will already have been jointly agreed between local authorities, ICBs and other key stakeholders. We have already given examples in paragraph 19 of areas that have clear shared outcomes.
  
  
  
  Goals or outcomes specific to one organisation should be taken forward by the relevant organisation, overseen where necessary by the appropriate regulator.

Leadership, accountability and finance

• How can the approach to accountability set out in this paper be most effectively implemented? Are there current models in use that meet the criteria set out that could be helpfully shared?
  
  Local place based partnerships – in particular HWBs, already have shared accountability for achieving the priorities of the joint health and wellbeing strategy. These are a good basis on which to develop shared accountability for the shared outcomes plan. Local authority health overview and scrutiny committees also have a role in holding HWBs and their partner organisations to account for achieving the ambitions set out in the joint health and wellbeing strategy. 
  
  
  
  It is important to recognise that true shared accountability is challenging within the different accountability arrangements for local authorities and the NHS. Local authorities are primarily accountable to their local citizens, through their elected representatives, whereas the NHS is primarily accountable upwards to the Secretary of State and Parliament, through NHS England.  The development of ICSs and place-based partnerships is a genuine attempt to introduce local, outward accountability within the NHS but this will always need to be balanced with the continued need for the NHS to focus on national expectations and targets set by Government. The commitment in the white paper to rationalise and reduce national outcome targets will undoubtedly help the NHS develop local accountability.
  
  
  
  Agreeing shared operating principles across health, local government and other partners will support a culture of shared accountability where all partners hold themselves and each to account. The LGA, in partnership with the Association of Directors of Adult Social Services, NHS Clinical Commissioners, the Association of Directors of Public Health, NHS Confederation and NHS Providers, agreed a set of underpinning operating principles for effective partnership working on health, care and wellbeing. They are: collaborative leadership; subsidiarity - decision-making as close to communities as possible; building on existing, successful local arrangements: a person-centred and co-productive approach: a preventative, assets-based and population-health management approach: achieving best value.
• What will be the key challenges in implementing the approach to accountability set out in the paper? How can they be most effectively met?
  
  The response in paragraph 24 above also sets out the challenges of differing accountability mechanisms for the NHS and local government. A key challenge is that NHS partners will be accountable for local priorities set out in the joint health and wellbeing strategy and the integrated care plan, and national priorities set out in the refreshed NHS Long-term Plan and the NHS England system operating framework. This can be minimised by the refreshed NHS Long Term Plan recognising the imperative for ICSs and place based integration partnerships to focus on a small set of priorities that will make the most positive impact on system and place-based health challenges. 
  
  
  
  Another challenge to shared accountability is lack of coterminosity between ICS place-based partnerships and local authority places.  This makes it all the more important to align new accountability arrangements with existing ones, for example HWBs.
• How can we improve sharing of best practice regarding pooled or aligned budgets?
  
  All areas have a range of existing arrangements for pooled and aligned budgets. We would be happy to work with DHSC and NHSE to identify examples of good practice in order to spread best practice.
  
  
  
  Creating more confidence in each ICS to pool greater proportion of existing budgets through existing BCF/Section 75 mechanisms is crucial to ensuring that pooled or aligned budgets are expanded in scope and size.
• What guidance would be helpful in enabling local partners to develop simplified and proportionate pooled or aligned budgets?
  
  Since pooled budgets, using s75, have been in place for many years, we recommend that any guidance is clear, short and focused on sharing good ideas and practice. It is important that the Government seek the views of directors of adult social services on their experience of pooled and aligned budgets to ensure that any changes work to the benefit of local government and the NHS.
  
  
  
  We also need to focus on expanding pooled budgets at the level of the individual through integrated personal budgets for health and social care direct payments. We are committed to working with people with lived experience, the Government and the NHS to identify national  action to increase the availability of shared personal budgets, including looking at how we can simplify processes for people to benefit from direct payments and personal health budgets.

• What examples are there of effective pooling or alignment of resources to integrate care or work to improve outcomes? What were the critical success factors?
  
  Critical success factors include the buy-in of senior leadership, flexibility to tailor to local circumstances, clarity about risk and reward, and clarity about the benefits to be accrued from pooling or aligning budgets, within a shared vision. Examples include where local areas have pooled significantly more than the BCF minimums, such as Salford or Sheffield, or the similarly broad perspective of local agreements across Greater Manchester. It is worth noting that areas with a good track record of pooling and aligning budgets all have a long history of joint working, built on trust, strong relationships from top to bottom, the ability to overcome short-term or specific tensions in order to work towards shared objectives.  

Digital and data

• What are the key challenges and opportunities in taking forward the policies set out in this paper?
  
  Interoperability between health and care systems is a key dependency and the national approach to working with social care data system providers is crucial to integration.  The LGA has worked closely with Government and NHS England to ensure that the needs of adult social care are considered in joining up digital systems. Local authorities are likely to experience substantial and costly changes to social care data systems and in other technology developments such as telecare. There are particular challenges for developing shared data systems in areas where ICS and local authority boundaries are not co-terminus.
  
  
  
  Digitising social care records is a key step towards achieving an integrated shared care record (ShCR) across both health and social care. This is something we strongly support as outcomes for people are greatly improved if we all have the right information at the right time and can share one version of the truth. The increased support for social care providers to move towards having a digitised care record has been essential and has been a good example of where the right central support and investment from government can have positive impacts for adult social care.
  
  
  
  The need to develop and provide a comprehensive digital learning offer for the social care sector is essential in enabling the roll out of digital technology. It is welcome that the Digital Data and Technology profession is being recognised within the NHS Agenda for Change and that AI skills are supported through the AnalystX community, but digital skills coverage and recognition must also extend to adult social care.
  
  
  
  We support ICSs to each have a population health platform and digital investment plans and local authorities have to be at the centre of this, working with health colleagues. At present, digital plans for ICSs are focused on integrating and collating health data. Whilst this is essential, local authority information must not be viewed as an add-on. In taking an ‘ICS first’ approach to digital systems it is important that the needs of local government and social care are not overlooked.
  
  
  
  Up to 2025, there is significant capital investment required to implement these digital technologies and systems without any additional funding for councils to cover this. It is therefore essential that funding and support is provided across the board to all councils for them to meet these mandates. This is critical given the necessity of digital and data for integrated, person-centred care.
• How do we best ensure that all individuals and groups can take advantage of improvements in technology and how do we support this?
  
  
  
  Continued investment and support are required across the sector to ensure that shared care records can truly deliver their full potential. We strongly support that everyone should have full access to their shared care record and this needs to be a key consideration.
  
  
  
  All ICSs and place-based partners need to address digital exclusion as a major barrier to individuals and groups. Health and social care professionals will need to support individuals to improve their skills and confidence in using digital tools and resources to access care and support and manage their own care, and to ensure that they have access to digital platforms. However, there will always be a significant number of people who do not have access to or who are unable to use digital platforms and we must ensure alternative means of information, advice, help and support to access to care and support records and manage their own care.  

The health and care workforce and carers

• What are the key opportunities and challenges for ensuring that we maximise the role of the health and care workforce in providing integrated care?
  
  Arguably, workforce is the key factor upon which the whole policy stands or fails. The challenge is the continued predominance of the NHS workforce over the adult social care workforce.  There is a marked discrepancy between the pay and conditions of service of the NHS and the adult social care workforces, which needs to be addressed in order to ensure workforce capacity across health and social care providers. As well as differences in professional status, it is important to note that NHS staff work for one organisation and social care staff work for at least 20,000 providers.
  
  
  
  As well as equity in pay, a shared core competency framework across health and social care for some role would increase understanding and trust, and encourage a shared view of the skill resources within a system.
  
  
  
  There is a real opportunity for ICSs and place based partnerships to work with their own providers, communities and educational and training organisations to ‘grow their own’ workforces – especially in relation to adult social care and healthcare assistants, link workers in multi-disciplinary teams and discharge hubs, and in rehabilitation, intermediate care and reablement roles.  But the key challenge is the continuing lack of funding in adult social care in order to improve the pay and conditions of those working in adult social care. 
• How can we ensure the health and social care workforces are able to work together in different settings and as effectively as possible?
  
  It will be important to remove regulatory barriers that discourage free movement between health and care organisations. For example, currently there are barriers for public health professions to retain their accrued ‘years of service’ benefits (in calculation of redundancy payments and leave entitlements) if they move between sectors.  This requires regulatory change at national level.
  
  
  
  More generally, NHS professionals have little exposure to adult social care settings in the early stages of their career development. We strongly support any national, system-wide and local initiatives to ensure that every care and health professional is supported to develop an understanding of the whole system, including opportunities for shadowing, rotations across health and care settings, co-location, multi-agency teams and shared training and career development. We have heard anecdotal reports that in some areas, social care providers are expected to accept trainee nurses in their settings as part of nursing training but social care staff placements are not available in NHS settings. This lack of reciprocity is unhelpful.
  
  
  
  A further crucial component of effective joint working is the development of shared values and a shared culture which puts person-centred care and support, and an outcomes-based approach at the core of all practice.
• Are there particular roles in the health or adult social care workforce that you feel would most benefit from increased knowledge of multi-agency working and the roles of other professionals?
  
  While working in multi-agency settings would benefit all professionals in health, public health and social care, we feel that this would be of particular benefit to clinicians in influencing their practice.  One such example is that in cases where hospital doctors had been given training on strength based practice, this led to a significant improvement in the numbers of people being discharged home.
• What models of joint continuous professional development across health and social care have you seen work well? What are the barriers you have faced to increasing opportunities for joint training?
  
  With regard to adult social care, the fundamental challenge is the lack of a career development for senior care workers or any meaningful career structure in adult social care. There is a limited ability for many adult social care professionals to be released for training due to capacity pressures in the workforce.
  
  
  
  In brief the barriers to attracting and retaining people to a career in adult social care are financial, regulatory and the lack of recognition and esteem for adult social care professionals in comparison with their colleagues in the NHS.
• What types of roles do you feel would most benefit from being more interchangeable across health and social care? What models do you feel already work well?
  
  There is real potential to develop hybrid roles for less senior positions in reablement and neighbourhood team and in link worker roles, navigating across health, care, housing and the community and voluntary sector.
  
  
  
  Further opportunities for professional development, multi-skilling and co-location (some progress in integrated reablement and discharge teams), opportunity to extend to those involved in social prescribing/other community services/settings
  
  
  
  If care workers’ duties and skills are enhanced in line with proposals in the white paper, appropriate remuneration is required, and if not fully funded, places even more pressure on council budgets when medium-term solutions for social care funding remain outstanding. Professional liability insurance remains a key barrier to some aspects of the changes we need
  
  
  
  We particularly wish to highlight the status of social care nursing.  The campaign to attract people back to nursing during the pandemic succeeded in increasing nurses returning to NHS settings but it failed to attract any significant numbers into social care nursing.  We need to do more to promote the value of social care nursing and ensure parity with NHS nursing.  
  
  
  
  We also note the potential role and contribution of disabled and user-led organisations in support of place based working should also be considered in this context.