The LGA’s submission to Change NHS

We welcome the focus on the three shifts that the government has set out in its vision for the NHS – analogue to digital; treatment to prevention; and hospitals to community.  These are the right things to do. But these are not new. We have long known that this is the direction of travel needed to improve health outcomes and great work is happening across the country to shift in the right direction. But much more can and should be done.

This 10-year plan must therefore address why these shifts have not already been achieved. It must set out not only a vision for the NHS, but how the NHS will work as part of a wider system and with local partners, to address the state of the nation’s health. Boosting healthy life expectancy should be a focus for all. 

The NHS is one of local government’s most important partners. What each side does can impact the other; often positively, sometimes not. We know that the NHS plays a key role in helping us to live the life we want to lead, but it cannot do it alone. 

Whilst our response focuses on the role and experiences of local government, it is important to recognise the crucial role that the voluntary, community and social enterprise sector (VCSE) play in keeping people healthy and well. VCSE organisations offer huge amounts to local areas, through the services they provide, the wealth they generate, and the people they connect, engage and empower. They can be strong advocates amplifying the voice of service users, patients and carers. The importance of strong and constructive relationships between councils, health partners and VCSE must be recognised in the 10-year plan. 

Tackling health inequalities must be at the core of the 10-year plan for health. Woven through Lord Darzi’s recent diagnostic of the NHS were illustrations of inequalities facing people at all stages of life. It demonstrated that the challenges were not being felt equally. The 10-year plan must focus on the inequalities experienced by people across access, quality and outcomes. To meaningfully tackle the deepening inequalities, we need to truly embrace a left shift in priorities and back this up with the necessary activity and resources. This must be place based and build on data and insight rather and not solely focus on those already known to services. Integrated Care Partnerships already exist as a mechanism through which to focus on health inequalities.

It’s estimated that 15-20 per cent of the variation in health outcomes can be directly attributed to differences in healthcare. Health is about more than healthcare, and councils are vital in addressing the wider determinants of health through their role in housing, green spaces, sustainable travel including safe pavements for safe walking and roads for cycling, youth services, transport and their role in local economic growth. Essential services such as social care, public health and children’s services are key to improving population health and preventing ill health. 

Case study: Reducing health inequalities in Luton, the first ‘Marmot Town’.

It is essential that action on adult social care forms a core part of the 10-year plan – without this, real change and improvement to people’s lives and outcomes will not be possible. It is vital that adult social care is not left behind again and that a long term properly funded plan for social care reform to create a National Care Service is developed and the interconnections with the 10-year plan for health understood.  The absence of any announcements on reform, alongside severe escalating financial pressures, and increases in the volume and complexity of demand is becoming more and more of a concern across local government and the wider care sector. 

The 10-year plan, and the services and systems it sets out must be person centred – designed around the individual and the outcomes that are important to them. We are encouraged that the engagement process is putting the voice and experience of people who use and provide services at its core. This must continue to be an expectation going forward for all who commission and deliver services to build in real and meaningful citizen engagement and service user feedback. Services and the frameworks that sit around them must respond to people and their needs and not those of the organisations that deliver and commission them.

We want to shine a light on some specific cohorts given the scale of the challenges facing them: 

• Mental Health - Councils support and influence mental health and wellbeing in a myriad of ways. We need to move away from just focusing on mental illness to helping everyone stay mentally well. This means overhauling our attitudes and approach to mental health and mental health services, increasing investment in prevention, early intervention and life-time support. The three strategic shifts, need to be reflected in our collective approach to mental health.
• Children and Young People’s health and wellbeing - Children and young people are our future, yet they are too often overlooked. Too many do not have the happy and healthy lives they deserve. Our vision is that all children live in good homes, with access to healthy food and appropriate health services. The recently published Darzi report showed that this is simply not the case currently and reiterated the scale of the challenge – 1.2million children are living with obesity-related complications; and an 82 per cent increase in hospital admissions for eating disorders. The Darzi report found that the declining physical and mental health of children is closely related to wider social injustices, such as poor housing, lower incomes and insecure employment.
• Children with special educational needs and disabilities - The prevalence of mental health problems has risen significantly, and many more children are diagnosed with Special Educational Needs and Disabilities (SEND), such as autism, and unable to access the support they need. The education system is generally not incentivising or prioritising inclusion. Cost of living pressures are affecting many families. For children in care, there is a lack of high-quality placements and escalating costs for those with the greatest needs. These issues must be addressed to ensure children and young people receive the support they need, and that councils can make their full contribution to the Government’s mission.  Children with Education, Health and Care Plans (EHCPs) have seen performance flatline, or decline, across key educational milestones over the past decade. At the end of primary school in 2022/23, only 8 per cent of children and young people with EHCPs achieved the expected level in reading, writing and mathematics – exactly the same percentage who achieved that level in 2016/17. At the other end of the age spectrum, only 30 per cent of young people with EHCPs achieved Level 2 by age 19 compared with nearly 37 per cent who achieved this level in 2014/15. Dedicated Schools Grant (DSG) and high needs funding pressures are one of the biggest challenges that councils with education responsibilities are currently facing. This is the result of an ever-increasing need for SEND support and the growing number of children and young people who have an EHCP. 
• Working Age Adults - Adult social care is often seen primarily as a service for older people, but many who draw on services are younger, working-age adults with disabilities. While their aspirations—fulfilling independent lives, relationships and employment—may align with those of older generations, supporting them effectively requires a distinct approach. This report highlights the urgent need for focused attention on this group as we address funding and reform. The recently published CCN research – The Forgotten Story of Social Care – brings to life the scale of the challenge ahead.  40 per cent of people receiving adult social care support in England are working age individuals aged 18–64 with a disabled condition (a learning disability, a physical disability or a mental health condition) who make up the working age adult population, or individuals aged 65+ with a lifelong disabled condition (a learning disability or long-term mental health condition). National expenditure on social care support for working age and lifelong disabled adults has risen by over a third between 2020 and 2023 in England, with forecasts for the 2024 financial year even higher, despite the total volume of individuals in this population supported not having risen over this period. Whole system changes for working age and lifelong disabled adults based on their specific needs, not based on an older adults’ model, is needed. Case study: Lewisham Council - Making Lewisham an autism inclusive borough. 
• Frail and elderly - Our population is ageing. The number of people aged 65 or over in England will increase by 65 per cent in the next 25 years and we seen huge inequalities facing this group.  when people in the most deprived areas get to the age of 65, they have twice as many years of ill-health ahead of them as those in the least deprived areas, despite the fact they are also likely to live shorter lives.

We also want the 10 Year plan to address some of what we see as key enablers for sustained change. We set out our hopes in more detail in response to question 5, but provide a summary below as key things we would want to see addressed in the plan:

• Integration – A collaborative culture, systems and processes that promote joined up working from planning through to delivery, and system leadership are essential to realising the three shifts. Integration must be shaped around people and communities to deliver seamless services and improved outcomes; and not be about organisations and structures.
• Assurance and accountability - We remain supportive of the issues and recommendations highlighted in the Hewitt Review relating to assurance and accountability. Arrangements should be built upon outcomes. This will give local ICS and place-based partnership leaders the space and flexibility to focus on the prioritise that are most important for their communities. 
• Devolution – The forthcoming English Devolution Bill, combined with the development of the 10-year plan for health, provides a useful opportunity to explore opportunities for health devolution and better articulate the principles of subsidiarity.
• Better Information Sharing and better use of technology must create a step change in the ease in which service users can navigate the health and care system. 
• Workforce - The health system cannot succeed without a capable and motivated workforce of sufficient size and quality throughout that system.  

The financial position of adult social care remains seriously challenging. Surveys by the Association of Directors of Adult Social Services show that 63 per cent of councils overspent on their adult social care budgets in 2022/23. Of these, the proportion using their reserves to fund overspends increased from 37 per cent in 2021/22 to 72 per cent in 2022/23. 

Despite the strong evidence to support a push for care closer to home, resources are not flowing in the right direction. The Darzi report concluded that the NHS budget is not being spent where it should be – too great a share is being spent in hospitals, too little in the community. 

Whilst the infrastructure exists to support the pooling of resources and joint commissioning via mechanisms such as the Better Care Fund they are not consistently used to best effect.  Overly complicated reporting, and metrics which disproportionately focus on hospital discharge are challenging systems ability to shift towards communities. We are increasingly hearing examples of resources being used to cover the ‘bottom line’ and this is stifling innovation; damaging system relationships; and impacting on service user outcomes, most notably by those who would ordinarily have received continuing health care support. The 10-year plan must reflect the deficit position in terms of resources; relationships; and the workforces capacity to mobilise change. 

We welcome the shift towards neighbourhood working. This must be about more than co-locating services and buildings, and about working with natural geographies to understand local strengths and needs.  Joining up services at a hyper-local level to achieve a shared goal has been a feature of good integrated services and strong communities for many years. There is no one size fits all model for what good looks like - indeed the whole ethos of neighbourhood is what works in one area, might not work for others. 

The LGA are keen to work with trailblazers and health partners to understand the shared traits of areas that are already working in this way and better understand the blockages that may be preventing scaling and sustaining of neighbourhood working. A permissive menu built on good practice and sustained through regular evaluation and sharing of best practice will be key to achieving the outcomes that we all know neighbourhood working can deliver. We look forward to continuing to work with government to facilitate learning from the plethora of neighbourhood work underway.  

At a recent roundtable of local government leaders, the following themes emerged: 

• A strong recognition that any neighbourhood model must be couched in the context of strong relationships between local government, health and voluntary and community sector leaders.  They are so pivotal to delivering change that organisations and systems should be challenged when relationships are not delivering the changes needed.
• Outcomes - A relentless focus on outcomes and people is needed rather than settings and services.
• Changing the narrative – the narrative around social care, especially in integrated neighbourhood teams, needs to shift away from hospital discharge, and recognise the far greater role that it plays in helping people to pursue the things that matter to them most. 
• The process you use to get to the future, is the future you get.
• Learning– both from what is currently happening, but also from other change activity eg. Sure Start.
• The importance of creating safe spaces for local partners to try new things and understand impact.
• Data is important, but insight is essential to developing hyper local approaches that reflect need.

The public sector organisations that support health and care face significant challenges to make better use of technology this includes, but is not limited to, unequal funding to health and social care, market dynamics, digital skills, inclusion, and governance.  

Unequal funding: In recent years, there has been NHS funding made available for new digital systems where needed and for digital skills. In local government for social care, the funding has been limited, with only modest investment in commissioned providers (through the DiSC programme). This is creating a widening digital divide between the sectors. To address this growing digital divide between health and social care, there must be parity in funding and investment between health and social care digital transformation initiatives and for this to be embedded within wider digital transformation initiatives in local government.

Partners in Care and Health (LGA and ADASS) have also developed a local, regional and national self-assessment model for What Good Looks Like (WGLL) for digital working in adult social care framework, building on joint work with DHSC to establish the WGLL framework. 

Our LGA White Paper published in the Summer of 2024 we called for the establishment of a Local Government Centre for Digital (LGCDT).  The LGCDT will support the empowerment of local authorities to harness the potential of digital technology, driving innovation efficiency and improved services for communities across the UK. The LGCDT will provide a collaborative focus for local authorities, central government, industry experts and community stakeholders, to address unique challenges and opportunities facing Local Government in the digital age. By sharing knowledge, co-creating solutions, and driving innovation, the LGCDT will enable local authorities to overcome shared challenges and unlock new opportunities through collective action, like those laid out in this response.  

Market dynamics: Better use of technology in health and care is further challenged by the market as a large number of private sector providers hold health and social care data (18,000 private sector CQC registered organisations in adult social care provision) which enhances cyber security risks and makes data interoperability a challenge, a small numbers of IT suppliers hold large sections of the health and care market, such as with case management systems, and there are funding and data sharing limits to scalable technology innovation.  Work to support both the diverse market of suppliers holding data in health and care system and enhance cyber security standards across the market is needed.  There is an opportunity to build upon the Better Security, Better Care (BCBC) programme, increasing data security protection toolkit (DSPT) completion to >70 per cent beyond March 2025. 

In the digital management of adult and children’s social care in councils, such as case management systems, there are a small number of legacy suppliers which are hindering choice and limiting technological innovation. For example, in the Adult and Children's Social Care CMS markets, System C and Access Group, hold over 80 per cent of the market. Fostering a diverse digital technology supplier market in areas such as case management, encompassing both large tech firms and SMEs is essential to driving technological innovation. It is also essential that there is investment and joint working between central government and care providers to support this work. 

Incidences of technological innovation in health and care services are happening at a local and national level; however, this work is limited by scalability beyond proof of concept, single services or areas of care. To support greater scalability of SME-based solutions and to disrupt legacy markets, the healthcare system needs support SME suppliers and needs to invest itself in cloud-based platforms to enhance data sharing, invest long-term in digital migrations and upskill the workforce to support scalable solutions. To scale innovation, local systems also need to proactively create communities of good practice between different organisations in the health and care system. 

Skills and inclusion: Making better use of technology is also hindered by digital skills in the health and care industry. In all sectors of the health and care system, digital leadership is often not considered a priority at an executive level. This limits the ability of public institutions to implement tech-enabled programmes in cross-cutting services.  Social Workers, Occupational Therapists and other allied professionals have no national programme or national workforce strategy to contextualise the need for growing digital data and technology skills and need parity with NHS workers.   It’s crucial that investment is made to equip public sector workforces with the necessary skills and knowledge to manage and utilise digital technology, in particular AI, effectively. This includes skills to be able to evaluate the ethical and privacy considerations to effectively implement and challenge the AI. 

Governance: The health and care system struggles with fragmented data which is spread across numerous systems with inconsistent governance. Different trusts, ICB boards and local councils have different data collection methodologies, and storage on different software and governance processes which make it difficult to enhance data interoperability, inhibiting monitoring and improvements of health and care services. Also, currently, many local authorities get very little data insight at the local authority geography of interactions between their local populations, hospitals, Trusts and primary care. This leaves a significant gap in the intelligence needed to design effective local integrated services and needs to be urgently addressed. As previously mentioned it is vital that local government and the intersection of health and care with all council services  (including housing, schools and leisure) are considered in the design of data sharing standards, laid out in the new Data Use and Access Bill and there are also several general principles of data and digital services that we recommend are applied at all service levels to ensure data is shared and governance effectively and to the same standard: 

• All partners need to have access to digital and data systems – including local authorities and the community and voluntary sector.  
• As far as possible, aim for a single data set, accessed and used by all, so that all partners have a single version of the truth.  
• Maximise the use of existing data sets rather than creating new data collection and reporting burdens.  
• Be clear about the purpose of data reporting and collection – what problem are you aiming to solve by collecting this data?  
• Be clear about the benefits and costs of collecting data, collating it at system, regional and national level.  

The social care digital innovation programme (SCDIP) and social care digital innovation accelerator (SCDIA) projects provided several examples of broad digital interventions improving outcomes and productivity. The adult social care technology fund and accelerating reform fund (ARF) should also provide learning on innovation, including digital initiatives. 

Case study: 100% Digital Leeds: A Path To Digital Inclusion - Leeds Digital. 

Local government plays a critical role in health prevention and early intervention and must be seen as an equal partner to the NHS in influencing health outcomes. There is good, recent evidence on the long-term benefits of investing in prevention and early intervention, for example from the Sure Start programme the Troubled Families programme and FutureBuilders. 

Public health measures that prevent ill-health are more cost-effective than treating illness, leading to better outcomes for individuals and a more productive workforce. In adult social care, early support can prevent or delay the need for more costly acute services. The foundations for future health are laid in the earliest years of life. Investing in services such as health visiting gives children the best start in life, reducing pressure on GPs, hospitals, and social care later on. Health goes beyond healthcare, and local councils are crucial in addressing the broader determinants of health, including housing, green spaces, youth services, and the local economy. Reforming social care and investing in local government services are essential for a healthier population and a sustainable NHS. To effectively reduce pressure on healthcare systems, it’s vital to involve local government in shaping the long-term health strategy.  LGA analysis has found that, between July 2015 and 2024, the Public Health Grant received by councils has been reduced in real terms by £858 million (in 2022/23 prices). This has resulted in reduction in councils' ability to spend on public health commissioned services. 

Sustainable funding is vital, taking a more long-term, preventative approach to funding. This includes ending short-term prescriptive grants and moving towards shared outcomes framework and enabling greater freedom and flexibility in place-based budgets.

Case study: Vital 5 in Tower Hamlets.

In 2010, Professor Sir Michael Marmot outlined a clear rationale for ensuring that children have the best start in life “Giving every child the best start in life is crucial to reducing health inequalities across the life course. The foundations for virtually every aspect of human development – physical, intellectual and emotional – are laid in early childhood.”  Health inequalities not only have social costs, but economic impacts too – when the Marmot review was published in 2010 it was “estimated that inequality in illness accounts for productivity losses of £31-33 billion per year, lost taxes and higher welfare payments in the range of £20-32 billion per year, and additional NHS healthcare costs associated with inequality are well in excess of £5.5 billion per year.”  Preventative services, such as health visiting and school nursing, can make a critical difference here. For example, health visitors play a crucial role in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating before they reach crisis point. 

Our offer

We are encouraged by the process to develop this new 10-year plan for health. Only by doing things differently will we bring about the changes needed to create the shifts we need. People own what they help to create, and we are heartened by the steps that have been taken to really listen and engage with the sector. We have exciting opportunities ahead to do things differently and improve outcomes for our citizens by working together across 5 missions. 

Local government has great expertise and experience in providing cost-effective services that improve health outcomes. We want to continue to partner with the NHS in designing implementation plans that will work effectively in places to improve outcomes for residents. The Local Government Association will continue to support councils in driving service reform and implementing good practice. We need to continue to build an environment that not only values an improvement culture focused on outcomes, but a culture of learning and sharing, so those things that work can be scaled and replicated, where it makes sense to do so. Clarity of vision, sufficient time to scale and embed, robust commissioning arrangements and certainty of resources are all essential for this. 

Our asks

Oversight and accountability – quick to do

Let local leaders lead. Assurance, accountability, and oversight arrangements need to be built around outcomes and reflect how partners work together at system, place and neighbourhood.  Accountability upwards to NHS England and Government is important but so too is accountability outward to local citizens – elected members have a vital part to play in this. For too long there has been a democratic deficit in the NHS. ICSs need to work closely with councils and their elected members to ensure that their priorities in the integrated care strategies and plans for services in the Joint Forward Plans reflect local needs, concerns, and aspirations in a clear set of local ambitions for all partners.   The role of local authority overview and scrutiny also makes a major contribution to ensuring that the NHS is locally accountable.  

The LGA has consistently supported the ‘light touch’ and permissive approach of the Health and Care Act 2022 to give integrated care systems the flexibility to make their own arrangements for joining up services and set their own priorities and strategies for improving population health and addressing health inequalities.

Prevention - quick to do

Preventative services,  those that intervene earlier in people’s lives and reduce the need for later acute and reactive spend - are vital to people living fulfilled, happy and productive lives. They are also vital to addressing the drag on our economy from socioeconomic inequality and poor health. The LGA wants to work with the Government to improve outcomes and increase the efficiency of public spending by intervening at the earliest practical opportunity to minimise preventable disadvantage. We are asking the Government to enable greater local flexibility and to take a more long-term, broad-based approach to spending decisions to ensure that short-term savings do not impair more enduring social and economic outcomes. Key proposals are:

• Ensure that the potential long-term benefit of spending on prevention is routinely considered in both Treasury and departmental spending.
• Work with councils to strengthen cost-benefit analysis with an enhanced understanding of social return on investment and better tracking of long-term outcomes.
• Increase investment in the public health grant and in other vital areas of public health and prevention. At a minimum, funding should be restored to the public health grant, which has suffered a cut of 27 per cent in real terms since 2015/16.
• Implement the Hewitt report recommendation that the share of total NHS budgets at Integrated Care System level going towards prevention should increase annually by at least 1 per cent over the next five years. This should include commissioning strategies overseen by Integrated Care Partnerships.

Adult social care – quick to do / in the middle

The Health Mission rightly identified adult social care as being vital to ensuring that everyone can live an independent and prosperous life. Immediate investment to stabilise the here and now, and pave the way for longer-term reform, is needed. But investing in care and support must also be seen as a key enabler of delivering the Government’s mission to build an NHS that is fit for the future, particularly the move to a more preventative model of health and care. More broadly, given its scale and size, adult social care can play an important part in helping to the deliver the Government’s mission on economic growth:

• Provide immediate funding to alleviate the worst consequences of the current challenges, with the exact amount identified through a collaborative process across the care and support sector.
• End the reliance on council tax and the social care precept as a key means for funding adult social care.
• Commit to review NHS Continuing Healthcare.
• Provide new and dedicated funding to help kickstart a concerted effort to shift to a more preventative model of care and support.
• Take action on care worker pay.

Funding

‘Fixing’ the NHS will not solve the problems or achieve the outcomes that we all want. We recognise the resourcing challenges facing all public services but councils need a significant and sustained increase in overall funding that reflects current and future demands for services. In addition, the system for funding councils is out of date, opaque and urgently in need of reform. Councils need multi-year and timely finance settlements, and greater certainty over financial reforms, to enable them to plan ahead and make meaningful financial decisions. Financial certainty and stability will improve the value for money of local spending and enhance councils’ ability to drive public service reform and key government agendas and missions.

Workforce

The health system cannot succeed without a capable and motivated workforce of sufficient size and quality throughout that system.  This means there must be parity of esteem in word and practice between those working in the NHS and social care.  The LGA is keen to engage with the government’s plan to introduce a fair pay agreement in adult social care; local government has had effective sectoral collective bargaining for many years, but this can only succeed if sufficient budget is provided by central government to support it.  If central government continues to approach the two parts of the health system separately – for example in the treatment of employer national insurance increase cost burden, then the 10 year plan will be hampered by the continued two tier level of commitment that undermines the contribution adult social care can and should make to its success.

• Autumn Budget and Spending Review Submission 2024
• Local Government White Paper 2024
• LGA Our Vision for Children and Young People 2024
• Earlier action and support – The case for prevention in adult social care and beyond, 2024 
• Public Health Grant allocations to local authorities 2024/25: On-the-day briefing, 5 February 2024 | Local Government Association.