Collaborative place-based leadership
Local authorities are the convenors and connectors at place level. Through health and wellbeing boards (HWBs) and other partnerships, they are forging a collaborative culture in which partners from the NHS, local government, the community and voluntary sector, and communities themselves all contribute to joining up care and support. Place leadership – especially HWBs – is crucial to driving integration in partnership with ICSs.
- LGA offer LGA is committed to working with the Government and NHS England (NHSE) to develop a light-touch sector led improvement support offer to ensure HWBs all meet minimum requirements for leading on integration. The support offer will be based on a national assurance framework setting out the expectations for all HWBs. The core elements will focus on leadership, culture, behaviours, a shared evidence base, shared resources, joint strategies and clear governance arrangements.
Place as the primary building block of integration
Decision-making as close to communities as possible, with place usually being the most appropriate and effective level for driving joined-up care and support (Tackling delayed transfers of care in Bradford District and Craven).
ICSs will need to ensure that their place-based partnerships are either co-terminus or align as closely as possible with local authority places, since this is the footprint of many services they will need to work with – adult social care, children and young people’s services, housing providers, the community and voluntary sector.
- LGA offer – to provide examples of good practice of place-based action to join up resources, planning and delivery of integrated care and support, with evidence of an impact of better outcomes for individuals and populations.
Build on existing, successful local arrangements
We already have place-based structures and processes at place for driving integration.
- The Better Care Fund (BCF) has been a major impetus for local authorities and clinical commissioning groups to pool resources to join up the commissioning and provision of care and support. This has prevented hospital admissions, and when people do need hospital care, it has ensured that people have the right care and support to be discharged safely to resume their lives. In recent years however, the BCF has been dominated by the objectives of acute trusts to reduce delayed discharges and hospital length of stay. While both these objectives are important, a focus on these has drawn attention and resources on getting people through the ‘back door’ rather than on preventing people needing inpatient care in the first place.
- To better fulfil the ambitions around integration, the BCF should return to its original aspirations: to provide the right care, in the right place, at the right time in order to enable people to live independently within their homes, and when they need care and support to access this as close as possible to their home (Health and social care integration, National Audit Office. This means also a more equal and balanced relationship between the national BCF partners – the Department of Health and Social Care (DHSC), the Department for Levelling Up, Housing and Communities, NHSE and the LGA – in agreeing the policy framework and the national conditions and planning requirements (Leading for integrated care, The King's Fund and 2021 to 2022 Better Care Fund policy framework).
- Section 75 arrangements – the BCF is just one of the pooled budgets that many local government and health partners use to fund joined up services. In many areas, integrated services for people with learning disabilities and mental health needs are funded through Section 75 agreements (Integrating health and social care: North East Lincolnshire case study). We want to see far greater use of S75 arrangements to pool budgets and support, utilise lead or joint commissioning arrangements, and provide integrated or aligned provision so that preventative services are available in every place, and people can easily access the care and support they need to maximise their health, wellbeing and independence.
- Health and wellbeing boards are the statutory place-based forum for bringing together the professional, clinical, political and community leaders of a place to develop a shared evidence base (the joint strategic needs assessment) and agree a shared vision and priorities (the joint health and wellbeing strategy) to improve population health and wellbeing outcomes and address health and wider inequalities. HWBs have had a major impact on improving relationships across health and local government, championing change, driving integration and connecting with communities (What a difference a place makes: the growing impact of health and wellbeing boards). ICSs have a ready-made place-based forum to build on and link to in their place-based partnerships.
- HWBs as the governance for the key integration vehicle will need to be underpinned by joint or lead commissioning teams and other staff to deliver the local visions for integration.
- LGA offer – the LGA has a well-established and well-regarded sector-led support offer to help HWBs to improve their effectiveness as the key place-based connector and driver of integration, and to be supported by appropriate commissioning and/or delivery architecture. We are committed to working with Government and NHSE to develop our improvement offer to ensure that all HWBs are effective drivers of the integration agenda at place, and work effectively with ICSs.
- Additional leverage for HWBs to lead further integration – we believe that some HWBs are ready to take on additional responsibilities for joining up health and care services. We propose a pilot programme, funded by Government, to enable a small cohort of places to establish full joint or lead commissioning of some or all place-based community health and care services, with the HWB providing oversight and governance. This could include learning disabilities, mental health and physical disabilities, but precisely what is to be joined up should be determined as part of the bidding process. We will work with places to shape their proposals.
- Within these areas, there is the potential for the local authority chief executive to have a key role as the place based leader across health and care, similar to the current arrangements in some areas in which local authority chief executives are also the CCG chief officer.
- The accountability for enhanced and extended integration pilots would be to councils and the ICB through the HWB in the same way as existing S75 pooled budgets and lead commissioning arrangements are overseen. The learning from the pilots will inform the further development of integration, with the ambition for all HWBs to have the flexibility to assume this responsibility. And devolution to place should be part of the framework of any reforms, and not just limited to the pilot areas.
- LGA offer – we will work with the Government and NHSE to develop the pilot programme and to select leading edge HWBs. We will also work with the Government and NHSE to evaluate the impact of the pilot HWBs in joining up care and support to improve outcomes, and share the learning through our sector-led improvement offer. We will also support the chosen pilots to draw together a wider range of health and care services to provide better coordinated access, experience and outcomes to local people – looking for areas to be ambitious about what they can achieve.
A person-centred and co-productive approach
To ensure that integrated care and support enables individuals to live full and independent lives, rather than mired in structures and processes. National Voices sets out clear expectations of what people and their carers want from integrated care (Integrated care: what do patients, service users and carers want?):
- The aspects of care correlating most closely with good patient experience are relational. People and their carers want to be listened to, to get good explanations from professionals, to have their questions answered, to share in decisions, and to be treated with empathy and compassion.
- The people for whom integration is most relevant, those with long-term conditions or complex care needs, want the ‘system’ to combine two things in one place. They want knowledge to be seen as a whole person, and for professionals to consider their home circumstances, lifestyle, views and preferences, confidence to care for themselves and manage their condition(s), as well as their health status and symptoms. They also want knowledge of the relevant condition(s) and all options to treat, manage and minimise them, including knowledge of all available support services.
- Increasingly, multi-disciplinary teams from across the NHS, adult social care, the voluntary and community sector and housing are working together with individuals and their carers at place and neighbourhood level to support and enable individuals to live a full life (Integrating health and social care: Nottingham case study). ICSs need to enable existing person-centred support and to work with place-based leaders to develop them further (People helping people: Year two of the pioneer programme).
Wirral care home triage: Wirral has a large number of care homes and had a significant number of non-elective admissions from care home residents. They introduced a tele-triage service across 76 care homes, which gave an iPad and basic monitoring equipment to staff, who could use this to call on the advice of a nurse practitioner or GP when a resident become unwell. The service receives around 300 calls a month and only 15 per cent of residents require hospital treatment following the consultation. In terms of impact, there has been a 68 per cent reduction in NHS 111 calls from Wirral care homes, and a 10 per cent reduction in ambulance conveyances to A&E from care homes for 2018/19 compared to 2017/18 (
Wirral: care home teletriage service).
- LGA offer – to work with the Government, NHSE and other national partners to identify and share learning and good practice examples.
A preventative, assets-based and population-health management approach is the basis for improving health and wellbeing outcomes. The integration of health and care is often focused on supporting those with existing health and care needs. But we also need to refocus and reinvest in preventative and health-promoting services to enable people to maintain their health and independence (Integrating health and social care: Nottingham case study). In local authorities, public health teams lead the strategy for prevention, working closely with HWBs. Place-based health functions and councils including public health teams need to be adequately resourced so that they can invest in preventative measures.
Voluntary Action Rotherham is funded £500,000 to allocate money to voluntary and community organisations that are providing activities as part of its social prescribing programme. Analysis has identified an overall trend that points to reductions in service users' demand for urgent care interventions after they had been referred to the social prescribing programme. The estimated total NHS costs avoided between 2012-15 were more than half a million pounds: an initial return on investment of 43 pence for each pound (£1) invested (
Integrating health and social care: Rotherham case study).
- LGA offer – to work with the Government and NHSE to develop and share learning and good practice examples, and to continue to provide support to systems in how to develop and invest in preventative community models of health and care.
Achieving best value
We acknowledge that there is limited evidence that integration reduces the costs of care and support and /or improves access and outcomes. We need a stronger evidence base that pooling health and care resources is the most effective use of resources. We do, however, have some evidence on which to build a better understanding.
For example, a common problem across many systems is the over-prescription of care, where people are given a higher level of support than they actually need. There is evidence that multi-disciplinary teams are more consistent at prescribing support at the ‘right’ level. The LGA report on better management of hospital admissions found:
By focusing on the best care pathway for patients or service users , significant benefits can be realised in terms of improved outcomes, greater quality of services and financial savings. Efficiency savings of 7 to 10 per cent of the budget areas assessed in this project could be realised through approaches to health and care that are better integrated. This equates to efficiency savings of over £1 billion nationally across the health and care system" (Efficiency opportunities through health and social care integration: delivering more sustainable health and care).
- LGA offer – to work with the Government and NHSE to strengthen the evidence base for achieving the best use of resources through integration.
Flexibility and freedom of local leaders
We need to maintain and extend these in order for leaders to work together to agree shared ambitions that are right for their populations, taking into account their unique demography, health and care challenges, history of partnership working and health and care resources (West Yorkshire and Harrogate Health and Care Partnership). The top-down approach of national targets and priorities is a major barrier to them keeping a sharp focus on achieving local priorities for providing integrated care and support.
We recognise the Government’s role in setting the national policy agenda for integration, and in setting out national expectations but this should be a broad enabling framework rather than a prescriptive and directive approach to how and where resources should be deployed. It will be vital that NHSE, council and CQC self and formal assurance and performance monitoring processes expect and assess for progress on the greater integration of services at place, improved experience of people using services or needing information and extension of preventative services.
Evidence shows that local systems can most effectively address their challenges when they have the freedom and flexibility to find their own solutions. The imposition of top-down national conditions and targets also undermines the message that local health and care leaders have a responsibility to meet local challenges. For example, with regard to BCF, the national targets on delayed transfers of care may have led to temporary reductions but not necessarily the best outcomes for individuals, with funding and attention diverted from preventative, community based interventions. We need to work with place leaders so they own their own performance aimed at achieving sustainable improvements.