LGA response to NHS England and NHS Improvement consultation on integrated care systems

Integrating care: next steps to building strong and effective integrated care systems.


Introduction

The LGA welcomes the opportunity to give our views on the NHS England and NHS Improvement (NHSEI) consultation on proposals for integrated care systems. The LGA is the national voice for local government. We are a politically-led cross-party membership organisation that works on behalf of councils to ensure that local government has a strong, credible voice with national government and other national agencies.  Our core aim is to work with councils to support, promote and improve local government.

Our response to the consultation is drawn from the comments, concerns and experience of our member councils. Over the past three months we have organised and participated in a number of discussions with senior political and professional leaders from local government, the NHS, the voluntary and community sector to discuss the future of health and care in general, and the role and contribution of local government in integrated care systems and at place. We have also circulated briefings to our members to summarise the proposals and identify potential implications for local government. In turn, councils have shared with us their views and concerns.

Summary of the key LGA messages, questions and concerns

Placing ICSs on a legal footing and the form the legal entity will affect existing partnerships between the NHS and local government. It is vital that NHSEI engage councils, as essential and equal partners in health, wellbeing and care systems, at national and local level in developing these proposals.  The proposals must build on the strong and effective partnerships that already exist between the NHS, local government and other key partners at place level.  

We support the direction of travel of the proposals towards joining up health and care support around the individual, based on collaboration between organisations, and where decision-making is at the most local level. But the proposals are in danger of missing the real prize of collaborative place-based leadership to achieve greater investment in prevention and community-based health and wellbeing services, including a far stronger emphasis on mental health.  It is only by addressing the wider determinants of health – safe and affordable housing, access to training and good jobs, a safe and healthy environment, support for early years, infrastructure to support resilient communities and other encouraging our citizens to take an active part in their neighbourhood – that we will ensure accountable, sustainable and effective health and care systems that address health inequalities and improve population health. And it is only by working in equal partnership with local government that the NHS will be able to achieve this.

The swift and effective action of local government and the NHS at place and neighbourhood level during the pandemic has demonstrated the importance of collaboration between the NHS, local government and other key partners to drive change and deliver effective services. The proposals need to build on this by having a far stronger emphasis on commissioning and delivery of health, care and wellbeing services at place level. They also need to give far more consideration to the role of ICSs in working with their partners to shift care and support from hospitals to the community, as close to people’s homes as possible. Furthermore, the place needs to be meaningful to local people and, as the consultation document states, that place should be the local authority footprint. We also want to see more focus on planning and delivery at neighbourhood level, building a strong role for primary care networks working in partnership with councils.

We support the objectives of the NHS Long Term Plan but we have concerns about how the proposed changes will play out in practice. It is unclear whether this really is a step change in the NHS moving from a centralised, command and control organisation to one in which power and resources will be devolved to systems and places.  We are concerned that the changes may result in a delegation of functions within a tight framework determined at the national level,  where ICSs effectively bypass or replace existing accountable, place-based partnerships for health and wellbeing. Whilst there are a range of views and different systems are at different stages of development, a clear message from local government leaders is that we need to recognise that the NHS is not the whole system or indeed the main leader within an entire system.  The NHS cannot assume primacy and this change ought not promote that message.  Rather, as a statutory NHS body the ICS would be a key and welcome partner within the system.

Statutory reform of ICSs: It is essential that there is local government representation on ICS boards, whatever legal structure it takes. In our view, the ICS as currently proposed will be an NHS body with local government representation, not a partnership of equals across the whole system. 

We’ve received a range of views from councils across the country regarding their preferred option for the legal basis of ICSs. Some councils have expressed concern that creating ICSs as a statutory corporate NHS body will be a retrograde step and damage the collaborative and equal partnerships in many STPs and ICSs. Calling this body an integrated care system is to us a misnomer because it is primarily an NHS body, integrating the local NHS, not the whole health, wellbeing and social care system. For greater clarity, we propose that the statutory body should be changed to better reflect its function.

Some strongly favour Option 2 while others support Option I. The LGA can see that both have merits. Option 1- that ICSs will be a statutory joint committee - has the benefit of more able to act as strategic partnership body for the whole system.

With regard to Option 2, there is value of having a single corporate body across NHS organisations in a health economy. This should be effective in increasing collaboration and join up between NHS organisations in an area, with the ability to plan strategically and deploy resources to best effect.  But important though this is in improving access to health care, this is a different task to leading a partnership to address the wider determinants of health,  improve population health and address health inequalities. As a statutory NHS body the ICS would be a welcome and important partner within the system but the ICS is not the whole health and wellbeing system nor indeed the leader within an entire system. 

Whichever statutory model is chosen for ICSs, it is essential that there is a system level partnership in which local government and other partners work alongside the NHS to drive real change in health, care and wellbeing services; address the wider determinants of health, reduce health inequalities and improve health outcomes.   

We’ve heard from many local authorities that have emphasised the importance of co-terminosity between the ICS and councils and how difficult it is to plan with health systems whose footprints bear no relation to identifiable place and communities.  Co-terminosity is vital for the collaboration, partnership and integration necessary to meet our health and wellbeing challenges.

With regard to accountability for ICSs, the government will need to ensure local accountability through existing local democratic structures. It should be up to local councils and their NHS partners to decide on the accountability arrangements that are right for their area but we would expect a strong oversight role for health and wellbeing boards.

Whichever statutory model is chosen, we need clarity on whether ICSs will be the main vehicle for local government and NHS partnership. We are calling for a statutory  reciprocal duty of cooperation to address health inequalities on the NHS and local government. The effective operation of this duty would require an inclusive partnership that includes but goes beyond the ICS Board.

We are keen to work with the government, NHSEI and councils to look in detail at each option, and indeed other options, not considered in the paper, to understand their role and contribution to system-wide transformation of health and wellbeing. 

It is essential that most commissioning will still need to be at place and neighbourhood/primary care network level. Commissioning should only undertaken by ICSs only when there is demonstrable benefit in doing so. Some councils are concerned that ICSs may withdraw commissioning capacity at place level. This would not be helpful in commissioning appropriate, effective, localised and joined up health and care services. The document largely considers collaborative commissioning between NHS bodies and of joint committees of commissioners and providers.  Again, it is silent on the value of joint commissioning between the NHS and local government which is disappointing.  A lack of cross sector commissioning and provision will be a barrier to improved outcomes.

With regard to NHS services being removed from the scope of the Public Contracts Regulations 2015 we strongly call for the whole of the public sector to operate within the same legal framework wherever possible. Local government is subject to the Public Contracts Regulations so this proposal represents greater regulatory burden on local government.  We would be concerned if this difference created a barrier to existing or new joint commissioning arrangements, or if commissioning was inappropriately channelled through the NHS. 

Values and principles underpinning the proposals: the LGA, NHS Confederation, NHS Clinical Commissioners, NHS Providers, ADASS and ADPH agreed joint principles that must underpin effective integrated care. 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.

Some of these principles feature strongly in the consultation document, in particular collaborative leadership, subsidiarity, and achieving best value. We are keen to work closely with NHSEI to ensure that all of these principles underpin integrated working in all areas. 

Maturity and capacity of STPs and ICSs: We are in favour of ICSs with collaborative leadership, a commitment to devolving decisions and resources to place,  and a clear focus on improving population health outcomes.  Some areas are already making steady progress.  But not all system partnerships have operationalised the above principles. Immature systems may rely heavily on regional or national direction to undertake their new role.  We are concerned that this reliance may end up being hard-wired into some systems.

The LGA is working with NHSEI to further develop a sector-led approach to system leadership underpinned by the values at the heart of the reform – place, population health, collaboration.  We propose a phased approach to ICSs which would avoid immature systems being burdened with duties that they do not have the capacity to carry out effectively. Even if ICSs are created in all parts of England by April 2021, they should not be given powers and duties until they have demonstrated maturity, competence and partnership and this assessment must involve local government partners.

In support of greater integration, place based working and local accountability, the LGA is calling on the government to introduce:

  • a new statutory reciprocal duty of collaboration to improve population health and address health inequalities on all NHS organisations and local authorities
  • a legal requirement on ICSs to involve health and wellbeing boards (HWBs) in the development of plans and to devolve the development of place or locality plans to HWBs
  • a new power for HWBs to ‘sign off’ on all ICS plans
  • commissioning to continue to have a strong place-based focus, with a strong and proactive role in HWBs in approving commissioning plans
  • a statutory duty on ICSs to be accountable to their local communities through existing democratic processes.

LGA comments, questions and messages in detail

Section 1: Purpose

We strongly support the general policy direction: towards greater collaboration between NHS organisations and across the NHS and local government; a strong focus on population health and addressing health inequalities; a strong focus on place as the level at which change happens; and a clear recognition that local government are key partners in this transformation. Building on the NHS Long Term Plan, which barely mentioned the role of place and the importance of collaborative partnership between local government and the NHS, this document represents a welcome change in approach. That said, there is little explicit recognition of existing effective place-based partnerships, for example, HWBs.

The proposals are in danger of missing the real prize of collaborative place-based leadership to achieve greater investment in prevention and community-based health and wellbeing services, including a far stronger emphasis on mental health.  It is only by addressing the wider determinants of health – safe and affordable housing, access to training and good jobs, a safe and healthy environment, support for early years, and infrastructure to support resilient communities – that we will ensure accountable, sustainable and effective health and care systems that address health inequalities and improve population health.

It is too early to foresee how the relationship between national, regional, system, place and neighbourhood will play out in practice. It is not clear whether there will be genuine devolution of decision-making and resources to the most local appropriate level, or this will be limited to delegation from the national and regional tiers of NHSE and will stop at ICS level. It is also difficult to predict whether this represents true devolution of power and resources or whether it is simply delegation within a tightly controlled national framework. We are committed to working with government and NHSEI to ensure that power, resources and decisions are taken at the most local level.

Section 2: Putting this into practice

We welcome the recognition of the role of local government and the need to work at place.  However, there is no specific commitment to build on what exists – for example, existing integrated care partnerships and HWBs.

It is also disappointing that there is little consideration of wellbeing, the wider determinants of health or the role of councils in relation to economic and social drivers of health and wellbeing. We support closer working between providers and commissioners to plan and deliver better outcomes. We are also keen to support greater parity between providers: both within the NHS between acute, mental health, primary care; and between the NHS and other partners, especially local government, the voluntary and community sector and social care providers. It is only by working together as equal partners that we can develop effective joined-up and person-centred care pathways that improve health, wellbeing, independence and resilience.

With regard to governance and accountability, we urge NHSEI to build on existing place-based accountability arrangements, including HWBs and health overview and scrutiny arrangements.  Any additional governance needs to add to rather than duplicate or bypass existing arrangements. We also urge the NHS to work with local government partners to ensure that accountabilities within systems are clear, simple and facilitate joint working towards a shared objective. 

We strongly support joining up finances in a single pot to facilitate greater flow across the health and care system. We also welcome the commitment that ICSs will allocate resources according to national frameworks and local priorities. But it is not clear how will they balance the two if there be a tension between national and local priorities. Greater clarity is needed.

With regard to the proposal to remove the NHS from the scope of the Public Contracts Regulations 2015, we strongly call for the whole of the public sector to operate within the same legal framework wherever possible. This proposal would lead to a lack of alignment between NHS and councils which might be a challenge for  joint commissioning.

We urge NHSE to adopt the joint principles for effective integrated working agreed by LGA, NHS Confederation, NHS Clinical Commissioners, NHS Providers, ADASS and ADPH. They are: collaborative leadership; 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; and achieving best value.

Some of these principles feature strongly in the consultation document - collaborative leadership, subsidiarity, and achieving best value. However, the proposal to make ICSs a statutory corporate NHS body may undermine the commitment to collaborative and equal partnerships between the NHS and local government.  There is little concrete commitment to a person-centred and co-productive approach, and adopting a preventative, assets based approach.  There is also little recognition of existing local arrangements and building on these rather than creating new structures. This is disappointing and we urge more explicit recognition of HWBs as the key building blocks of ICSs. The LGA is calling on the government to introduce:

  • a new reciprocal statutory duty of collaboration to improve population health and address health inequalities on all NHS organisations and local authorities
  • a legal requirement on ICSs to involve HWBs in the development of plans and to devolve the development of place or locality plans to HWBs.
  • a new power for HWBs to ‘sign off’ on all ICS plans
  • commissioning to continue to have a strong place-based focus, with a strong and proactive role in HWBs in approving commissioning plans.
  • a duty on ICSs to be accountable to their local communities through existing democratic processes. 

Section 3: Legislative proposals

With regard to the four specific questions in the consultation document, our views are below.

A statutory footing for ICSs We supported the proposal for ICSs to be voluntary joint committees in the original proposed legislation.  However, we do recognise that progress toward system working needs greater impetus, which mandation will bring. We therefore support making ICSs mandatory in all areas but recognise that this legal requirement will need to be backed up with support for system leaders to work collaboratively to achieve population health outcomes and to devolve power and resources to the most local level. 

It is essential that there is local government representation on ICS boards, whatever legal structure it takes. In our view, the ICS as currently proposed will be an NHS body with local government representation, not a partnership of equals across the whole system.  Calling this body an integrated care system is to us a mis-nomer because it is primarily an NHS body, integrating the local NHS, not the whole health, wellbeing and social care system. For greater clarity, we propose that the statutory body should be changed to better reflect its function.

We’ve received a range of views from councils across the country regarding their preferred option for the legal basis of ICSs. Some councils have expressed concern that creating ICSs as a statutory corporate NHS body will be a retrograde step and damage the collaborative and equal partnerships in many STPs and ICSs.

Some strongly favour Option 2 while others support Option I. The LGA can see that both have merits. Option 1- that ICSs will be a statutory joint committee - has the benefit of more able to act as strategic partnership body for the whole system.

With regard to Option 2, there is value of having a single corporate body across NHS organisations in a health economy. This should be effective in increasing collaboration and join up between NHS organisations in an area, with the ability to plan strategically and deploy resources to best effect.  But important though this is in improving access to health care, this is a different task to leading a partnership to address the wider determinants of health,  improve population health and address health inequalities.  As a statutory NHS body the ICS would be a welcome and important partner within the system but the ICS is not the whole health and wellbeing system nor indeed the leader within an entire system. 

Whichever statutory model is chosen for ICSs,  it is essential that there is a system level partnership in which local government and other partners work alongside the NHS to drive real change in health, care and wellbeing services; address the wider determinants of health, reduce health inequalities and improve health outcomes.   

We’ve heard from many local authorities that have emphasised the importance of co-terminosity between the ICS and councils and how difficult it is to plan with health systems whose footprints bear no relation to identifiable place and communities. Co-terminosity  is vital for the collaboration, partnership and integration necessary to meet our health and wellbeing challenges.

Whichever statutory model is chosen, we need clarity on whether the government and NHS intend for ICSs to be the main vehicle for local government and NHS partnership. We are calling for a statutory  reciprocal duty of cooperation to address health inequalities on the NHS and local government. The effective operation of this duty would require an inclusive partnership that includes but goes beyond the ICS Board.

We are keen to work with the NHSEI and councils to look in detail at each option, and indeed other options, not considered in the paper, to understand their role and contribution to system-wide transformation of health and wellbeing. 

We seriously question whether all systems will have sufficient maturity and capacity to take on the wide-ranging responsibilities of ICSs by April 2022. We propose that ICSs should not be given powers and duties until they have demonstrated maturity, competence and partnership with local government.

Systems to shape their own governance arrangements  We strongly support systems having the freedom and flexibility to determine their own membership, beyond the statutory minimum. We would like to see a stronger emphasis on ensuring the system governance arrangements build on and enhance existing place and neighbourhood governance arrangements. They should not bypass, undermine or duplicate existing governance arrangements at place, in particular the accountability roles of HWBs and health overview and scrutiny arrangements.

Delegation of NHSEI commissioning to ICSs We strongly support delegation of NHSEI commissioning to ICSs, where appropriate. Furthermore, we would like to see far more emphasis on delegating commissioning to place and neighbourhood levels, ensuring the application of the principle of subsidiarity – that decisions are made as close as possible to the communities .  Furthermore, rather than delegation down, we want the default approach to commissioning to be at the place or neighbourhood level unless there is a compelling reason for it to be undertaken at a level more removed from local communities.

Section 4: Transition and next steps

We support the development of ICSs with strong collaborative leadership and a commitment to devolving to place to  improve population health and health inequalities. Some ICSs are already making strong progress.  But not all ICSs will have the maturity to take on commissioning and leadership responsibilities by April 2022, especially given the huge and ongoing impact of the pandemic on health and social care services, and health inequalities.

Immature systems may rely heavily on regional or national direction to undertake their new role.  We are concerned that this reliance may end up being hard-wired into some systems. The LGA is keen to work with NHSEI to develop a sector and peer-led approach to support ICS leadership development. We propose that even if ICSs are created in all parts of England by April 2021, they should not be given powers and duties until they have demonstrated maturity, competence and partnership with local government.

Contact

Alyson Morley
Senior Policy Adviser – Health Transformation
Email: alyson.morley@local.gov.uk