Integration and innovation: working together to improve health and social care for all

We support Integrated Care Systems (ICS) as a strong driver for integrating health services in a system through the Integrated Care Board (ICB) and an ICS Health and Care Partnership (ICP) as a partnership of equals with a duty to ‘produce a plan for health, social care and public health services’.  

• Parity between the ICS Board and ICS Health and Care Partnership - The white paper says that the ICS will set up the partnership and that local areas can ‘appoint members and delegate functions as they see fit’. It is not clear whether this means the ICS NHS Body (ICB) will set up the ICS Health and Care Partnership (ICP). The establishment of the partnership in each system must be a joint responsibility of the ICB, councils and other partners. We support local flexibility, with health and local government leaders working as equal partners, to agree the forms of and relationship between ICB and the ICP that works for each area and which build on existing effective partnerships at place.   
• Terminology - Calling the ICS Health and Care Partnership the ICP is confusing. Many place-based joint arrangements are called integrated care partnerships already and ICP can also refer to ‘integrated care provider’. Why not stick to ICS Health and Care Partnerships? 
• A clear commitment to addressing health inequalities - The white paper states that the Health and Care plan will focus on ‘health, social care and public health services’.  This service-based approach is not helpful. It needs a broader objective of improved population health outcomes and reducing health inequalities, which will involve a far wider range of strategies and services across the public, private and community sector.    
• A whole population approach - There is very little reference to children and young people’s health in the white paper. In adopting a population health approach, ICSs will need to work closely with public health in local government, education, early years services and the private and voluntary sector to improve the health and wellbeing of children and young people.  Getting support right from pregnancy and early childhood will have lifelong impacts and needs a far higher priority because of its long-term benefits. 
• Footprint - We strongly support the commitment that, wherever possible, the ICS footprint will be coterminous with the local government footprint (councils with ASC responsibilities). We urge the Government to resolve any problematic ICS footprints at the earliest opportunity through a transparent transition process that involves all relevant councils and NHS organisations.  
• Primacy of place and subsidiarity – The governance within each ICS – at system, place and neighbourhood levels – must be underpinned by subsidiarity. ICSs will need support to ensure that decisions will be taken at the most local appropriate level. This must be agreed between partners at neighbourhood, place and system, not just by the ICS. ICS structures need to build on existing place-based partnerships, in particular health and wellbeing boards (HWBs). In some places, partners will need to review them to ensure that they are fit for purpose.  In others, new system and place -level partnerships will need to be developed and they will need support to do this, learning from their peers and existing good practice elsewhere. 
• Accountability - Accountability mechanisms within ICSs between the ICS NHS Board and the ICS Health and Care Partnership, and between the ICS and existing governance bodies such as HWBs, existing integrated partnerships and joint committees will need to be clearly mapped and agreed by all partners. This mapping will need to ensure that decision-making is as local as possible, transparent and accessible to local people.  
• Inclusion and co-production – ICSs need to develop plans and services in collaboration with the communities within their systems.  Engagement and inclusion mechanisms at system level need to build on and add value to existing place-based and neighbourhood mechanisms.   
• Keep bureaucracy to a minimum – ICSs should not lead to unnecessary additional layers of bureaucracy, more rules, reporting and processes. 

We support giving ICS NHS Boards the freedom and flexibility to agree Board membership, aside from a few key mandated members.  It will be up to ICSs to agree local authority representation in collaboration with all relevant local authorities.  ICBs and their partners will need to consider the best way of ensuring local accountability and transparency, joining up health and social care and support, and taking a population-health approach based on system-wide public health intelligence and advice.  We strongly recommend that ICS NHS Boards consider how they will involve public health, adult social care and children’s health and wellbeing professionals in their work. They will need support, drawn from existing and emerging good practice, to ensure an inclusive process for agreeing Board membership.   

Commissioning - Local clarity about commissioning at system, place and neighbourhood - ICSs should be encouraged to commission collaboratively across partners and the system, but it is important to avoid a national template for commissioning at system, place and neighbourhood. All areas are different. Instead, national expectations on subsidiarity will be helpful, learning from existing good practice, for example at least one ICS has agreed that it always works locally, unless the issue passes one or more of the following tests:  

• it is necessary to work on a bigger geography to achieve a critical mass to get the best outcomes  
• across the geography there is an unacceptably high variation in outcomes – and working together will improve quality, reduce variation and learn from best practice  
• there is opportunity to attract resources, energy or new thinking to long-term, complex, intractable problems and improve outcomes. 

We are pleased that the DHSC has heard and 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 flexibility for systems to develop their own Heath and Care Partnerships that are built on existing partnerships and which reflect each system’s unique combination of experience, assets and challenges.  

Health and Care Partnerships will need to give serious consideration to how they can best build on place level partnerships.   Many such partnerships, often HWBs, 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 DHSC and NHSEI to develop a coordinated support offer to help these partnerships to reach their full potential.   

The ICS Health and Care Partnership must be equal with the ICS Board in terms of its status and level of influence. ICSs will need to give careful consideration of how they ensure the balance of power between the two components.  

The LGA has long called for a shared duty of collaboration to improve health and wellbeing and reduce health inequalities so we are pleased to see this proposal. We will work with DHSC and NHSEI to draw on existing good practice to escalate the scale and pace of collaboration and to make this a meaningful duty.  Therefore, we are calling for this duty to be clarified as a duty to collaborate in order to improve health and wellbeing and address health inequalities. We will also need to work together to consider how this duty can be overseen, what levers and incentives there are at local, system, regional and national level to support systems to implement it. 

Whatever the system architecture, ICSs will need to have a strong and meaningful relationship with the HWB/s within the system. This will depend on the existing arrangements. In areas where the ICS and the local authority share a footprint, the ICS Health and Care Partnership may agree to merge with the HWB or delegate some of the responsibilities of the ICS to the HWB.  In areas where an ICS encompasses more than one HWB area the HWBs could using existing joint arrangements or develop new joint HWBs to address strategic issues. For example, two neighbouring councils that share an ICS footprint have formed a joint HWB that deals only with strategic issues so that it can contribute effectively to the ICS.  

The NHS and local government will need to work together to develop their own arrangements. We can support them by providing examples of existing good practice. It is important that NHSEI does not develop a limited menu of options but allows all areas flexibility to develop their own arrangements, learning from existing good practice.  

We understand that changes to the current procurement rules for the NHS will not lead to an uneven playing field between local government and the NHS. Any measures to reduce procurement requirements on the NHS must not, inadvertently, create barriers to joint commissioning or local authority-led commissioning, or cause commissioning to be inappropriately channelled through the NHS and local government partners to work collaboratively. Councils will need to revisit their existing procurement and commissioning governance processes to consider new processes and any future reporting requirements.  

The procurement Green Paper Transforming Public Procurement outlines a proposal to remove the current Light Touch Regime (LTR) that is used extensively for education, health, and social care commissioning.  We have concerns on the thresholds for the LTR and the timescales. This expenditure – most of the local government procurement spend and about 8 per cent of all public procurement spend – is not adequately addressed in the Green Paper. 

Whilst we could support the proposal to remove LTR (which would be superseded by a new flexible procedure) we believe that:  

• the inclusion of personal care or aspects of it in the proposed new healthcare procurement legislation merits serious consideration;  
• to the extent that social care is covered by the new regulations contemplated by this green paper there must be specific provision for service user choice; and  
• that the higher threshold of £663,000 should remain for any education, health or care contracts that remain in scope, to reduce administrative burden. 

With regard to powers of the Secretary of State (SoS) to intervene in NHS reconfigurations, we are concerned that this may undermine the existing powers and duties of local authorities. We will seek clarification that the existing powers and duties of local government are not undermined or by-passed.   

The Secretary of State’s powers need to be consistent with the general principle of resolving disputes as locally and as early as possible. They should not allow the SoS to intervene and bypass health local or joint overview and scrutiny arrangement, or allow the NHS to refer reconfiguration proposals directly to SoS to avoid local opposition.  The SoS should be required to operate these powers only in exceptional circumstances and to do so in partnership with local overview and scrutiny arrangements.  

We understand Government’s desire for greater transparency in social care. We welcome the fact that local government has so far been  an equal partner in the initial discussions about what  a national oversight framework might look like; this must continue in the weeks and months ahead. We are also encouraged that all partners involved in discussions about adult social care assurance recognise the vital role that sector led improvement plays and will continue to play; again, this recognition must continue to underpin future work in this area, with assurance building on existing sector led improvement work, recognising local democratic accountability and giving a meaningful voice to people who draw on and work in social care.  

We favour a review-driven approach looking at whole systems, based on a shared agreement of what good looks like, a person-centred approach and locally flexible care and support.  

Any new processes for assurance and oversight need to be accompanied by a New Burdens assessment to fairly capture the resource implications for councils and others in meeting new regulatory approaches.  

Any assurance process has the potential to highlight shortfalls in services and delivery of the intentions of the Care Act due to resource constraints. Any assessment of a council’s adult social care services would need to be contextualised in terms of available resources.  

With regard to data sharing, we strongly support the commitment in the white paper to greater sharing of data between health and social care, in particular between local government and primary care. These will need to be underpinned by inclusive data sharing protocols.  

We recognise Government’s desire for a mechanism that routes funding to social care providers quickly. Local decision-making, local knowledge of the provider market, and local democratic accountability are essential components of the system of social care funding and should not be bypassed. It is, therefore, helpful that the white paper makes clear this power will be used only in exceptional circumstances.  

We propose a legal requirement for the Secretary of State to consult with local commissioners before making any such direct payments in order to avoid disruption of the local care market.  

SoS power to direct NHSEI to take on specific health functions - It is unclear whether the changes relate only to public health functions exercised by NHS England and Improvement or equally to public health functions exercised by local government. Any legislation needs to be clear on which requirements apply to which parts of the public health system. The LGA will be seeking clarity on the Secretary of State’s power of direction. 

Measures to reduce obesity - We support proposals to strengthen front-of-pack nutrition labelling and calorie labelling on alcohol. We believe a single system will help people make informed choices.   

We also welcome plans to ban advertisements of products high in fat, sugar or salt being shown on TV before 9pm. It is disappointing that the white paper did not give councils powers to ban junk food advertising near schools - something that councils and the LGA have campaigned for. 

Water fluoridation - Whilst we welcome the shift to a more streamlined consultation process for water fluoridation schemes, water fluoridation must not be imposed on communities.  

It has been the long-standing policy that local decision-makers are best placed to consider locally-expressed views and to balance the perceived benefits of fluoridation with the ethical arguments. Local authorities have encountered difficulties with the current consultation process, including the fact that local authority boundaries are not coterminous with water flows, which requires the involvement of several authorities in these schemes.   

Reform of public health – the national structures for public health and health protection are currently being reorganised. It is crucial that the new structures for public health are aligned with the new structures for the NHS at regional and system level, recognising that place based public health teams are the leaders of public health.  

Legislative powers and duties, and statutory guidance are important drivers of change. But they are not the only drivers, nor even the most important ones.  

Culture change and collaborative leadership – System working to improve population health requires a collaborative culture in which leaders across the NHS and local government have an individual and collective responsibility to look beyond their organisational boundaries to achieve the best outcomes for their community.  This requires time to develop trust, confidence and a shared understanding between leaders across places and systems, and a strong leadership development offer based on a peer-led approach.  

A shared and single version of the truth – encompassing shared ambitions for health and wellbeing and addressing health inequalities, a shared evidence base on the challenges, priorities and assets of each system and each place and neighbourhood within systems. And a shared strategy that identifies how system, place and neighbourhood will work together to meet the challenges. 

Common principles and expectations – Systems must have the freedom to determine their own priorities, models of governance and modes of delivery but these should be underpinned by clear national expectations of the common principles for all ICSs. These operating principles should be: demonstrable commitment to an all-age approach to population health, including children and young people’s health and transitions from CYP to adult services; an outcomes-focused approach to addressing health inequalities, engaging the wider determinants of health; adherence to the subsidiarity principle; and ensuring that all components within the system identify and deliver their contribution.  

Implementation and development support – ICS, place and neighbourhood leaders across local government and the NHS and beyond will need support in developing a new culture and approach.  The LGA already works with DHSC, NHSEI, NHS Confederation, NHS Providers, ADASS and ADPH to plan and deliver a range of sector-led, peer-led support and improvement offers.  We need to build on the support already available and review, adapt and extend it, according to the development needs of leaders.  

Single outcomes framework - and a shift to pay for outcomes rather than inputs to get the incentives right to prioritise the things that really matter.  

Financial flows – We strongly support the presumption that unless there are explicit reasons, the majority of non-elective health and care budgets will be delegated to place level. We also propose greater alignment of local government and NHS resources at system level. Legally, local authorities cannot agree to spend their budgets in a different local authority area unless for a joint service.  Therefore, alignment or pooling of NHS and council resources will almost always need to be at or within HWB footprints.  

Lack of decision on the future of social care remains a barrier to long-term planning and joining up health and care support. 

Unnecessary and disproportionate national prescription and bureaucracy and overly ambitious and unrealistic timescales for implementation. National priorities that are unreasonable in ambition and/or timescale, and/or do not allow ICSs the flexibility to address their own priorities. An unduly nationally directed approach risks undoing and destabilising existing partnership arrangement, and undo the progress made during the pandemic. 

Top-down imposition of models of partnership, governance structures or outcome targets and/or the development of guidance or expectations without input from all sectors or parties affected. 

The continued dominance of the acute sector in ICSs will hinder a more preventative, population health approach.  

Continued dominance of the NHS in partnerships – DHSC will need to ensure and equal partnership model of ICSs and an equal balance of power between the NHS, local government and other partners.