This briefing sets out the LGA's response to different parts of the Government's health and social care integration white paper. We welcome the recognition that achieving better health and wellbeing outcomes for individuals and communities is the primary purpose of integration, but achieving the scale of ambition set out will require long term commitment from Government, local government and NHS leaders at every level.
Introduction and background
This briefing summarises the key proposals outlined in Health and social care integration: joining up care for people, places and population, published by the Government on 9 February 2022. It also gives the LGA’s initial key messages on the proposals.
The white paper is one of a suite of reforms of the health and care system, including the Build Back Better: Our Plan for Health and Social Care, the Adult Social Care Reform white paper, People at the Heart of Care, the Health and Care Bill, (currently in the Lords stages of the parliamentary process) and reforms to the public health system. Its aim is to escalate the scale and pace of health and care integration to improve access, experience and outcomes for individuals and populations.
The white paper sets out progress on integration and a powerful case that joined up and person-centred care and support is better for people and places; leads to better services and better health and wellbeing outcomes; and makes the best use of NHS and local authority resources. It also emphasises the need for a preventative approach to build health resilience in people and places. It acknowledges the progress that has already been made, including through the Better Care Fund, Sustainability and Transformation Partnerships, health devolution and the joined-up response to support and protect communities through the pandemic.
The Government sets a clear vision for integrated health and care services:
“Integration is not an end in itself, but a way of improving health and care outcomes. 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. Our vision is that integration makes a significant positive impact on population health through services that shift to prevention and address people's needs promptly and effectively; but it is also about the details and the experience of care - the things that often matter most to people, carers and families.”
It also emphasises that integration should be the ‘golden thread’ at all levels: individual, neighbourhood and community; place; system and national. The main focus of the white paper is place level in recognition that this is the level at which most health and care planning and delivery takes place. It also underlines that effective place leadership of integration is vital for effective ICSs and neighbourhood working.
The white paper does not explicitly address children’s social care, but it emphasises that places are encouraged to consider the integration between and within children and adult health and care services wherever possible. The Government will consider and respond to the findings of the Independent Review of Children’s Social Care, which is expected to report later this year.
It sets out the measures for:
- developing shared outcomes for person-centred care, improved population health and reducing health inequalities
- giving a strong role to place-based working and leadership to complement the strategic role of integrated care systems (ICSs)
- a single place-based leader accountable across health and social care to deliver shared outcomes
- using key enablers – workforce, digital and data sharing and financial alignment - to join up services
- robust regulatory mechanisms to support the delivery of integrated care at place level.
Summary of key proposals
The key proposals of the white paper are summarised below. The Government will:
- consult stakeholders and set out a framework for shared outcomes with a concise number of national priorities and approach for developing additional local shared outcomes, by Spring 2023
- review alignment with other priority setting exercises and outcomes frameworks across health and social care system and those related to local government delivery
- ensure implementation of shared outcomes will begin from April 2023
- on leadership, accountability and oversight, set an expectation that by Spring 2023, all places should adopt a model of accountability and provide clear responsibilities for decision making including over how services should be shaped to best meet the needs of people in their local area.
- review section 75 of the 2006 Act which underpins pooled budgets, to simplify and update the regulations
- work with partners to develop guidance for local authorities and the NHS to support going further and faster on financial alignment and pooling
- publish guidance on the scope of pooled budgets in Spring 2023
- work with the Care Quality Commission (CQC) and others to ensure the inspection and regulation regime supports and promotes the new shared outcomes and accountability arrangements at place
- develop a national leadership programme, addressing the skills required to deliver effective system transformation and place-based partnerships, subject to the outcomes of the upcoming leadership review
- publish a final version of the Data Strategy for Health and Care (Winter 2021/22)
- ensure every health and adult social care provider within an ICS reaches a minimum level of digital maturity
- ensure all professionals have access to a functionally single health and adult social care record for each citizen (by 2024) with work underway to put these in the hands of citizens to view and contribute to
- ensure each ICS will implement a population health platform with care coordination functionality, that uses joined up data to support planning, proactive population health management and precision public health (by 2025)
- develop a standards roadmap (2022) and co-designed suite of standards for adult social care (Autumn 2023)
- enable one million people to be supported by digitally enabled care at home (by 2022)
- on workforce, strengthen the role of workforce planning at ICS and place levels
- review barriers (including regulatory and statutory) to flexible movement and deployment of health and care staff at place level
- develop a national delegation framework of appropriate clinical interventions to be used in care settings
- increase the number of clinical practice placements in social care during training for other health professionals
- improve opportunities for cross-sector training and joint roles for adult social care and NHS staff in both regulated and unregulated roles
- appoint a set of front-runner areas in Spring 2023 to trial the outcomes, accountability, regulatory and financial reforms discussed in this document.
Summary of LGA views
The LGA welcomes the values underpinning the white paper, and its ambition and scope, putting 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 and care outcomes.
The LGA has long argued that integration is not an end in itself but a means of achieving better health and wellbeing outcomes for individuals and communities. 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. We look forward to seeing this reflected as the ICS and wider reforms are rolled out in practice.
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 likely to be directed through the voluntary and community sector.
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 national outcomes framework which allows place and system leaders to identify their own priorities. We also welcome the expectation that all places will work collaboratively to develop their and drive forward their own outcome plans.
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.
With regard to a single accountable officer, it will be important for local government and the NHS to agree arrangements based on what is locally appropriate. In many places, they may wish to consider joint appointments to this role.
In determining place boundaries, 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 . Many of the 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.
The paper takes a 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 somewhat 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. 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 for 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 but 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.
Developing effective leadership and accountability
The white paper underlines the key role of clinical and professional place based leaders to deliver outcomes that matter to people and populations, ensure value for money and tackle health disparities. The Government will develop a national leadership programme, informed by the Messenger Review of Health and Social Care Leadership, to ensure place leaders have the right skills.
Without pre-empting the Messenger Review, the white paper outlines the leadership skills required at place: an ability to work collaboratively around a common agenda; sound judgment on removing and challenging organisational boundaries; a strong focus on and plan to delivery outcomes, based on shared data and a holistic understanding of population health needs; a twin focus on the delivery of care and support and population health; an ability to listen to people who draw on services; and support to clinical and care leadership.
The Government has set out criteria for governance and accountability for all places within an ICS for the delivery of shared outcomes with the expectation that all places adopt an appropriate governance model by Spring 2023. The white paper sets out a model for a place board but it recognises that there is huge variety in the configuration of places and ICSs so there will, inevitably be variation in place-based governance and accountability arrangements. The key components common to all will be:
- a clear, shared plan with agreed shared priority outcomes
- measures for reshaping services within place
- practical arrangements for managing risk, resolving disagreement between partners
- evidence of performance delivery against the shared outcomes
- pooled and aligned resources to achieve the plan
- a single accountable place leader, agreed by the local authority and integrated care board (ICB)
- boundaries of place based partnerships to align with existing ICS boundaries, as far as possible.
Shared place outcome plans should build on and enhance existing place-based plans to improve services and improved 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. We expect these to be the basis of shared outcome plans unless agreed otherwise by place leaders.
With regard to a single accountable officer, it will be important for local government and the NHS to agree arrangements based on what is locally appropriate. In many places, they may wish to consider joint appointments to this role.
In determining place boundaries, 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 . Many of the 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. We expect these footprints to be the default footprint unless agreed otherwise by place partners
With regard to the expectation that place governance and a single accountable officer will be agreed by Spring 2023, we recognise that systems and places will need to work together to develop aligned governance arrangements. In areas with simple system and place configurations, this may be a reasonable timescale but in other areas, where the system footprint cuts across local authority boundaries, this may be more challenging.
Financial framework and incentives
The white paper recognises that financial frameworks for health and care have often been cited as a barrier to integration. Furthermore, NHS and local government partners have often had to develop complex ‘work arounds’ to overcome them. The white paper reiterates that local leaders should have the flexibility to use their joint resources to meet the particular health needs of their population, either through formal pooling arrangements or less formal alignment.
NHS and local authorities will be supported and encouraged to increase the use of pooled and aligned budgets to ensure better use of resources and also to support long-term investment in population health and wellbeing.
The Department of Health and Social Care (DHSC) will develop guidance for local authorities and the NHS to escalate the scale and pace of financial alignment and pooling. DHSC will also review existing legal powers for pooling budgets (Section 75 of the NHS Act 2006) to simplify arrangements.
The white paper acknowledges that the BCF has been a strong driver for pooling budgets in most areas, with many areas voluntarily increasing the amount pooled above the mandated minimum.
It also underlines the ambition to expanding the use of personal health budgets and the national roll-out of the NHS’s comprehensive model for personalised care to give people more choice and control over how their healthcare is planned and delivered.
The white paper requests views on the following questions:
1. 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?
2. What will be the key challenges in implementing the approach to accountability set out in the paper? How can they be most effectively met?
3. How can we improve sharing of best practice regarding pooled or aligned budgets?
4. What guidance would be helpful in enabling local partners to develop simplified and proportionate pooled or aligned budgets?
5. What examples are there of effective pooling or alignment of resources to integrate care / work to improve outcomes? What were the critical success factors?
6. What features of the current pooling regime (section 75) could be improved and how? Are there any barriers, regulatory or bureaucratic that would need to be addressed?
We welcome the emphasis that place based leaders need the flexibility to deploy pooled or aligned resources to their own priorities. This will require ICSs to work collaboratively and inclusively with place leaders. While we support the greater use of pooled and aligned budgets, their use needs to be seen in the wider financial context for the NHS, adult social care and public health.
The LGA has raised the urgent need for the Government to address immediate and medium-term funding of adult social care. Without adequate resources for adult social care and public health, local authorities will be limited in their ability to contribute to pooled and aligned budgets.
The LGA welcomes the review of existing legal powers, including Section 75 and we urge the DHSC to work closely with local government in undertaking the review.
Oversight and support
Digital and data: maximising transparency and personal choice
The white paper underlines the importance of digital and data as a key driver for several aspects of integration, with following expectations:
- to empower people to have greater control of their own health and care, through the increased use of digital health apps, all citizens, professional and carers to have a single health and care record by 2024
- by 2025, each ICS will implement a population health platform that uses joined up date to support planning and population health management and public health
- by 2022, one million people will be supported by digitally enabled care pathways at home
- all health and adult social care providers must reach a minimum level of digital maturity and should be connect to a shared care record
- NHS and local authority organisations, including place boards, should have access to a common data set to understand population health and health disparities in order for ICSs place boards to plan, commission and deliver shared outcomes, including public health and prevention services
- NHS and care staff will have support to increase their basic digital, data and technological skills so that they are confident in recommending digital interventions to users of health and care services.
ICSs will be expected to develop digital investment plans to outline how ICSs will ensure data flows across all care and health setting and how digital technology will be used to achieve person-centred and proactive care and support at place level.
In order to increase transparency for citizens and service users, DHSC will look to introduce mandatory reporting of outcomes for local places.
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. 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 rather than an add on to be completed post 2024.
We support the use of terminology standards and strongly urge these to be developed alongside the adult social care sector with comprehensive engagement.
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.
We strongly support the focus on digital and data and the ambitions to continue to move forward at pace. This pace must be inclusive of all parts of the health and care sector.
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.
Delivering integration through workforce and carers
The white paper emphasises that the health and care workforce is the most important asset and that they need to work together to meet the needs of populations and places.
It sets out proposals for ensuring that there is joint workforce planning at system and place levels to meet the local population needs. The key proposals are summarised below:
- strengthening the role of workforce planning at ICS and local levels
- reviewing the regulatory and statutory requirements that prevent the flexible deployment of health and social care staff across sectors
- increasing the number of appropriate clinical interventions that social care workers can safely carry out by developing a national delegation framework of healthcare interventions
- exploring the introduction of an Integrated Skills Passport to enable health and care staff to transfer their skills and knowledge between the NHS, public health and social care
- increasing the number of learning experiences in social care, including health undergraduate degree programmes and for those undertaking apprenticeships
- exploring opportunities for cross-sector training and learning, joint roles for ASC and health staff in both regulated and unregulated roles
- promoting the importance of the roles of link workers, care navigators and care coordinators to ensure consistent access to these roles across the country
- building on proposals laid out in the workforce chapter of Adult Social Care Reform white paper, People at the Heart of Care, which are:
- a knowledge and skills framework, careers pathways and linked investment in learning and development to support progression for care workers and registered managers
- funding for Care Certificates, alongside significant work to create a delivery standard recognised across the sector. This will improve portability, so that care workers do not need to repeat the Care Certificate when moving roles
- continuous professional development budgets for registered nurses, nursing associates, occupational therapists and other allied health professionals
- investment in social worker training routes
- Initiatives to provide wellbeing and mental health support, and to improve access to occupational health
- a new digital hub for the workforce to access support, information and advice, and a portable record of learning and development
- new policies to identify and support best recruitment practices locally
- exploration of new national and local policies to ensure consistent implementation of the above, as well as higher standards of employment and care provided.
The white paper has a strong focus on different professionals working together within and across organisations towards a person-centred model of care and support for health, wellbeing and independence. It also recognises that partnership working goes beyond health and care professionals and extends to professions working in public health, community health services, education, housing and homelessness services, and the voluntary and community sector, and also unpaid carers.
In terms of workforce planning, the white paper sets out the respective responsibilities at national, ICS and place levels. The DHSC will support improved workforce planning at place level by: strengthening guidance for ICSs on the need to work with place; encouraging the development of local workforce forums to identify and build on good practice; supporting places to develop a ‘one workforce’ approach; and considering the need for further national action, following the publication of the long-term strategic framework (expected later in 2022).
With regard to movement between health and social care sectors, the white paper restates the need to make it easier for the workforce to move between health and social care. It refers to the measures set out in the Adult Social Care Reform white paper, People at the Heart of Care to improve career pathways and progression within adult social care, and to support local areas to recruit people with the right skills and values to meet care needs now and in the future.
Place-based workforce planning will help to prevent duplication of roles and consider the impacts of one sector on the other. ICSs will have the flexibility to create place-based committees to plan care, in recognition that it is the level at which workforce makes integration a reality – including community multidisciplinary teams that are co-located to bring together the right professionals focused on getting the best outcomes for individuals.
The white paper seeks views on the following questions:
- What are the key opportunities and challenges for ensuring that we maximise the role of the health and care workforce in providing integrated care?
- How can we ensure the health and social care workforces are able to work together in different settings and as effectively as possible?
- 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?
- 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?
- What types of roles do you feel would most benefit from being more interchangeable across health/social care? What models do you feel already work well?
Key to workforce planning at system and place is parity of esteem, pay and conditions and recognition between the NHS and social care workforce. In its response to the Adult Social Care white paper the LGA notes that while much of the ambition for the workforce is to be welcomed, it will not hang together cohesively without proper action on pay.
Reference to the NLW does not answer the pay question because it will not allow the sector to become competitive with the NHS and other key employers. Indeed, it could exacerbate existing difficulties with recruitment and retention. The delegation of further clinical activities to care workers will have to be supported by training and a transfer of resources.
We support the commitment to working with commissioners and providers on terms and conditions. Pay must be a central element of this and should take the form of an independent review, as we have long called for. Without meaningful transformation on pay, many of the ideas put forward in adult social care white paper (such as a Knowledge and Skills Framework to support career structure and progression) will be hard to deliver because people will have no guarantee of increased pay and reward for their increased skills and may continue to use social care as a stepping-stone to the NHS or other opportunities outside of the sector.
Both health and care employers are facing significant workforce shortages, with well-publicised existing high vacancies for nurses, care workers and therapists. The number of people leaving both sectors is also rising. Without significant action on recruitment, retention, wellbeing and coordinated planning, the ambitions in this white paper will not be able to succeed. We urge the government to work collaboratively with employers, leaders, unions and others to collectively address these shortages in the short and longer term.
The skills passport proposal could be an important innovation if it provides a proper recruitment link between employers and prospective employees and if it links properly to the knowledge and skills framework proposed in the health and care white paper. Detailed consultation with employers is needed to make this work properly as well as considerable investment and we welcome early moves to discuss the issues
The proposal around potential regulatory change to ensure more flexible movement around the system is interesting and important. The LGA has long advocated such changes to ensure public health staff can move between NHS and Local Government without losing aspects of continuity of service and this and other changes will be important for widescale workforce integration.