The LGA broadly supports the Bill’s focus on improving the health and wellbeing of the population and the duty of bodies to have regard to this in making decisions. We are strongly in favour of the duty to engage with patients, carers and representatives and hope and expect that there will be further guidance to help bring this to fruition.
- The Health and Care Bill seeks to remove barriers to integrating services to improve health outcomes and reduce health inequalities.
- The LGA broadly supports the Bill’s focus on improving the health and wellbeing of the population and the duty of bodies to have regard to this in making decisions. We are strongly in favour of the duty to engage with patients, carers and representatives and hope and expect that there will be further guidance to help bring this to fruition.
- The requirement for NHS integrated care boards and local authorities to establish a health and care partnership with responsibility for producing an integrated care strategy is helpful. It is good to see recognition of the importance of Health and Wellbeing Boards and the health and wellbeing strategies and joint strategic needs assessment they produce.
- We support the Government’s intention that the legislation will give local systems the flexibility to make their own arrangements for joining up services and setting their own strategies for improving population health. The Government needs to co-produce regulations and guidance in partnership with local government and the NHS, to ensure that the intentions set out in the white paper are realised - for most services to be commissioned and delivered locally and to build on existing successful arrangements.
- The repeal of legislation related to delayed discharges is good news and paves the way for the continuation of discharge arrangements which have worked well during the pandemic.
- The provisions for assuring local authorities’ adult social care functions set out a new role for the CQC and the Secretary of State in the review and performance assessment of councils. We are working closely with the CQC, the Department and other partners to ensure the assurance process is proportionate, includes a clear and continuous role for existing sector-led improvement work, and takes account of the significant financial pressures facing adult social care.
- We have some concerns regarding the power of the Secretary of State to call in NHS reconfiguration proposals as the role of local health overview and scrutiny committees in these matters should not be undermined.
- While many provisions in the Bill relate to the practical steps the NHS must take to reorganise governance, staff and budgets, it is vital that clinical, professional, political and community leaders at local, system and national level stay focused on the broader and more challenging ambition for clinical, political, professional and community leaders to work together to improve health and wellbeing and reduce health inequalities, which have widened further during the pandemic.
The Health and Care Bill was published on 6 July 2021. The explanatory notes to Bill set out the case for a new legislative framework to facilitate greater collaboration within the NHS and between the NHS, local government and other partners, and to support the recovery from the pandemic.
Many of these proposals were set out in the NHS’ recommendations to Government to help deliver the aims of the NHS Long Term Plan and have already been the subject of an NHS England consultation, following which the Government published a White Paper These proposals recognise that the whole health and care system, including local government, has a vital role in addressing the health and wellbeing challenges of our populations. In addition, there are proposals of relevance to local government on social care and public health.
This briefing will cover our views on all provisions in the Bill relevant to local government.
LGA commentary on the provisions in the Bill
Integrated Care Systems (ICSs)
Integrated Care systems will comprise an NHS Integrated Care Board (ICB) and an Integrated Care Partnership (ICP). In England, Integrated Care Boards will be established as statutory bodies. The ICB will be responsible for the day to day running of the NHS, while the Integrated Care Partnership will develop an integrated care plan to address the system’s health, public health and social care needs. Public and ‘patient voice’ will be important in both bodies. The dual structure recognises that there are two forms of integration that will be enshrined in legislation: integration within the NHS to enable NHS organisations to work together across a system; and integration between the NHS, local authorities and other partners to deliver improved outcomes for health and wellbeing of their populations. The ICB and relevant local authorities will be required to establish an ICP, bringing together wider partners across the NHS, social care, public health and wider stakeholders.
We support the creation of a statutory NHS Body to integrate health services in a system and welcome the intention to establish an ICP to ensure there is a partnership of equals that can set out plans for improving population health and delivering better and more integrated care and health services. We support local flexibility and we are keen to support health and local government leaders to work as equal partners in setting up the ICS Health and Care Partnership. We have many examples of existing effective partnerships and are keen to work with DHSC and NHSE to promote these as examples of good practice.
We welcome the recognition that each ICS will need to agree how the ICB and ICP work together and be held to account through the different accountability mechanisms for local government and the NHS. It will be important for any new national accountability mechanism to build on and enhance existing local democratic accountability, not bypass or undermine it.
Integrated Care Board
Putting ICBs on a statutory footing will give them decision-making powers and responsibilities for NHS system performance, delivery and sustainability. It will also allow NHS England to have an explicit power to set a financial allocation or other financial objectives at a system level.
The ICB will be responsible for the day to day running of the NHS and have specific requirements to develop a plan to meet the health needs of the population within their area, to set the strategic direction of the system and develop a capital plan for NHS providers in their system. The ICB will be required to meet the system financial objectives which require financial balance to be delivered.
It will also take on the commissioning functions of clinical commissioning within its boundaries and some of those of NHS England. It will be able to delegate commissioning and functions to place level partnerships and provider collaboratives.
With regard to membership and governance, the Board will be directly accountable for NHS spend and performance, comprising as a minimum a chair, the ICS chief executive, representatives from NHS trusts, general practice, and one local government representative. The Board will need to ensure that it has appropriate clinical advice. The chief executive will be the accounting officer for NHS money allocated to the NHS ICS body.
The NHS ICS Body will take on CCG responsibilities in relation to local authority overview and scrutiny committees.
We support putting ICBs on a statutory footing as one way of promoting greater collaboration between NHS organisations and enabling them to focus on shared, system-wide objectives for improving health outcomes, improving care and support and making best use of resources.
Integrated Care Partnership
The ICP key role will be to develop an integrated care plan to address the health, social care and public health needs in its system, to which each ICB and local authority will be required to have regard. Membership of the ICP could include representatives of Health and Wellbeing Boards (HWBs), local Healthwatch organisations, the voluntary and community sector, social care providers, housing providers and other partners involved in health and wellbeing.
We are pleased that the Government has acted on local government’s calls for a wider health and care partnership to promote collaboration and equal partnership beyond the NHS. We strongly welcome the commitment to ensure flexibility for systems to develop their own ICPs. ICPs will need to give serious consideration to how they can best serve people in their area and will need to be mindful of what is and could be best delivered at place level and how to build on this.
Many such partnerships are already firmly embedded and making strong progress. We can learn from these areas to promote good practice elsewhere. The LGA is committed to working with the Government and NHS England to develop a coordinated implementation support offer to help these partnerships to reach their full potential.
Duty to cooperate
There will be a duty to cooperate on the ICB and local government. This will replace two existing duties to cooperate. Additionally, NHS bodies will have a duty to achieve the triple aims of the Long Term Plan: better health and wellbeing, better quality healthcare and ensuring the financial sustainability of the NHS.
The LGA have long called for a shared duty of collaboration so we are pleased to see this proposal. We are keen to work with the Government and NHS England to draw on existing collaborative planning and delivery to encourage and support all areas to escalate the scale and pace of collaboration.
The role of place
Though there is little on the face of the Bill regarding the importance of place-based leadership, the White Paper underlines the importance of ‘place’ as where joining up of care and support is most effective. Place, in most cases, will be the defined by the local authority ‘place’. ICSs will be most effective if they focus on delivery at place level, with recognition of the uniqueness of each place in relation to their population, geography, and history of partnership working.
It is vital that regulations and guidance support the intentions set out in the White Paper that local areas will be free to develop their own place-based partnerships, between the NHS, local government and health and care services, building on existing arrangements where they are working and with NHS England and ‘other bodies’ to provide support and guidance. Furthermore, guidance and regulations will need to emphasise that HWBs will continue to have a place level leadership role in driving partnerships, and producing joint strategic needs assessments and joint health and wellbeing strategy, to which ICSs will be required to have regard. HWBs and ICSs will be supported to work together to complement each other. ICSs will be required to work closely with HWBs and have regard to the joint strategic needs assessments and the joint health and wellbeing strategies within their system.
We strongly support the emphasis on place and the need for flexibility and freedom for local areas to develop their own place-based partnerships and to build on existing health and wellbeing boards and local delivery partnerships. We are keen to provide coordination information and a support offer with DHSC and NHSE for system and place leaders to develop a shared understanding of the role of place in driving forward collaboration to improve health and wellbeing.
Other proposals on how to facilitate collaboration within the NHS
In addition to ICSs, there are several other proposals to facilitate greater collaboration between NHS organisations:
- Collaborative commissioning – There are a range of provisions to allows NHS England and ICBs to work together in different ways to commission services, similar to Section 75 arrangements, which enable local authorities and CCGs to exercise joint commissioning, lead commissioning and pooled budget arrangements.
- Joint appointments – New provisions will allow NHS bodies to make joint appointments with other NHS bodies and with local authorities to drive joint decision-making, deliver integrated care, and engender a culture of collective responsibility across organisations.
- Data sharing - There are provisions to ensure data sharing across health and care, including a requirement to share anonymised information to the benefit of the health and care system. There will be new powers for the Secretary of State for Health and Social Care to require data from all registered social care providers about all services they provide, and require data from private healthcare providers and to mandate standards for data collections and storage.
- Patient Choice – The aim of these proposals is to strengthen patient choice and control. A key proposal is to repeal section 75 of the Health and Social Care Act 2012 including the Procurement, Patient Choice and Competition Regulations 2013 to replace with a new provider selection regime, which requires bodies that arrange NHS services to protect, promote and facilitate patient choice.
These proposals remove some of the barriers to greater collaboration between NHS organisations and as such we support them. In particular, we support measures that will improve data sharing between the NHS and local government and other partners at local level. We will be keen to ensure that any new data requirements or standards do not add to the reporting burden for social care without providing a proportionate benefit, that the sector is involved in their design and, where possible, that suppliers of systems are required or encouraged to adapt their systems centrally to new standards and outputs. Any new burdens on local authorities associated with the implementation of new standards needs to fully funded.
Most of the provisions in the Bill are concerned with reducing bureaucracy and streamlining processes to enable joined up working within the NHS. For this reason, they are not summarised in detail in this briefing. In brief, they relate to competition with the NHS, arrangements for commissioning and providing healthcare services, adapting the national tariff so that it is not barrier to collaboration between NHS organisations, the creation of new trusts by the Secretary of State for Health and Social Care and removing the requirement for Local Education and Training Boards.
The LGA will keep a watching brief on developments with regard to reducing NHS bureaucracy to assess whether they have any significance for local authorities. NHSE has published a consultation on NHS procurement.
We support provisions which reduce unnecessary and cumbersome requirements on commissioners and providers of NHS services. However, we are keen that the NHS and local government commissioning are aligned. The DHSC will need to ensure that any measures to reduce requirements on the NHS do not, inadvertently, create barriers to the NHS and local government partners working collaboratively. We believe that councils and health partners will need to revisit their existing procurement and commissioning governance processes to take into account the new processes for procuring health services and any other services procured alongside and any future reporting requirements.
Regarding the power of the Secretary of State to create new trusts, we urge the Government to ensure that the existing powers of local authorities are not undermined or bypassed by this new provision. The Government will need to consider what impact this will have on the powers and duties of the NHS and local authorities in relation to the reconfiguration of NHS services. Currently, the NHS has a duty consult any local authorities that are affected by any substantial variations or reconfigurations of health services.
Enhancing public confidence and accountability
These provisions are primarily focused on the NHS accountability arrangements. It includes proposals to allow the Secretary of State to intervene in local services configuration proposals ‘where required’
With regard to powers of the Secretary of State to intervene in NHS reconfigurations, we are concerned that this may undermine the existing powers and duties of local authority Health Overview and Scrutiny Committees relating to local NHS reconfigurations. We continue to seek assurances from the DHSC that the existing powers and duties of local government will not be undermined or by-passed.
While we appreciate the Government and Parliament’s desire for greater accountability of the NHS to them, we are concerned that no consideration is given to increasing accountability of the NHS to local people. We urge the Government to ensure that any new powers will not undermine local democratic accountability mechanisms.