Written evidence submitted by Coproduce Care CIC (ICS0052)

Contents

Comment on the inquiry and lessons learnt

Coproduce Care CIC is an apolitical non-profit organisation made up of volunteers who work in different roles across social care. We have consulted with our network to create this submission and give particular thanks to David Smallacombe, CEO of Care and Support West and Oona Goldsworthy, Chief Executive at Brunelcare for especially in-depth interviews and feedback.

This report is in relation to the Health and Social Care Select Committee’s inquiry into “Integrated Care Systems: autonomy and accountability”. The Select Committee launched the inquiry in July 2022 to ‘consider how Integrated Care Systems will deliver joined up health and care services to meet the needs of local populations’. The aim of the inquiry was to understand how ICSs will be able to operate with the flexibility and autonomy required in order to tackle inequalities in the populations they serve and whether the pursuit of central targets can be consistent with local autonomy.

About us

Coproduce Care was established in 2019 by people working in social care who were frustrated with the general and political lack of understanding of the social care sector. Members of Coproduce Care set out to enable policy makers to hear the views, voices and experiences of those working in social care and also, where possible, to represent those who draw from social care services and their networks. We use our online platforms to make sure care is understood by a wider group of stakeholders. Our successful media channel includes interviews with dozens of sector leading experts, senior politicians and lawyers. These have included interviews with over 100 people including Martin Green, Gillian Keegan MP and Mayor Andy Burnham, as well as experts by experience such as Isaac Samuels.

Some of our most popular work includes submissions to the Cabinet Office and Ministry of Justice as joint submission responses from our network on policy and law change such as the Mental Capacity Act Code of Practice. We have also held online conferences such as a recent event on the Care Quality Commission’s Out of Sight report, watched by over 15,000 people.

We have always worked to connect different groups affected by social care and this turned into an emergency response during the Coronavirus pandemic. We chaired and organised weekly online meetings and platforms with over 150 care providers in our local area and professionals with the aim of fostering connections and collaboration to aid joint solutions to the COVID19 pandemic. Expert guests to these calls have included our regional CQC inspection manager, deputy mayor Councillor Asher Craig and academics from Bristol University, public health and AHSNs.

Breakdown of our consultation groups:

We sent out a survey to our members with the questions required for this inquiry.

We held 1:1 conversations with stakeholders within our network to gauge their experiences and good practice examples in relation to ICSs. Some of those conversations included with the CEO of our local care association, Care and Support West and leaders of local social care services.

Comment on the inquiry and lessons learnt

This inquiry is extremely welcomed by our network in social care. This is due to the fact that there is often little recourse to feedback to senior leaders on the experience of ICSs from a social care perspective. We did however, encounter some obstacles with this particular inquiry. Whilst the overall scope of the inquiry is clear, the individual questions came across as quite specific and technical to our stakeholder group. Most of the questions assumed prior detailed knowledge of the legal and technical remit and structure of ICSs and we had trouble with getting feedback from our network due to them not being quite sure what the questions were in reference to. Questions such as ‘What does a permissive framework look like in practice?’, were difficult for people to understand and we ran out of time to provide a response to this after we gained clarification from the committee. Therefore, most of our response is in relation to more general feedback on ICSs, how they are integrating with social care and the extent to which their decision making is either inclusive of or coproduced with the social care sector.

“I’ve been concerned that adult social care isn’t at the IC board level. Adult social care needs to be at all levels.” (respondent)

The integration of social care

All of our respondents felt that social care was not incorporated into either the ICBs or at the partnership level enough. This may have been due to the fact that partnerships were still being developed and formalised. Also there was a general consensus that involvement in an ICS from social care representatives such as social care provider associations, had to be lobbied for until there was acceptance onto the relevant board or partnership group. One such council which has started to include the care provider association and its board members is Bristol City Council. This has come after much close working and assertion from the association chair David Smallacombe over the past two years. This involvement however, has not been seen universally for the areas which the care association works in.

However, there is still an issue with who from social care is involved within ICSs. At the moment where social care is included into either the ICPs, ICBs or the wider partnership working, there is a focus on care provider organisations. There is a concern that the other parts of social care are not included in partnership working at any level. Possible partnership stakeholders could include disabled people’s organisations, personal assistants, family carer organisations or representatives and most importantly, people who draw on health and social care services and/or their representatives. The actual client groups are not represented as standard and very rarely even in good practice.

There is also a concern that the ICSs have left it very late to incorporate even care providers into their leadership teams. So, overall the integration piece has been within health and NHS services, to the exclusion of social care.

Summary of responses

How best can a balance be struck between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for doing so?

Our respondents did not feel that there was much of a conflict here. One respondent in particular felt that they had to work differently to ensure accountability to local residents, clients and the local community and therefore had to allow for a level of flexibility. Another respondent was concerned that many of those heading up ICSs were not elected members apart from directors of health and social care who could, although not directly, be considered as partly elected. But this is something that could be further explored and developed.

Are central targets consistent with local autonomy in this context?

Most of our respondents felt that central targets were not consistent with local autonomy and that there should be some levelling out. They understood that with the large amounts of money that needed to be accounted for, there needed to be targets, but that there should be focus on targets which chime better with the needs of the community, such as ambulance waiting times.

To what extent is there a risk that ICBs become an additional layer of bureaucracy if central targets are not reduced as ICBs are set up?

Our respondents reported that there are opportunities for ICBs to reduce bureaucracy by looking at the wider care system and linking in with data already collected elsewhere in the system rather than creating additional administrative burdens. There was a general concern as to how they would be made to be accountable and the lack of understanding of ICBs about commissioning within their area, not least because of a lack of involvement of provider organisations and/or associations.

“Most of the people who lived [worked] in CCGs are now in the ICS and sit on integrated partnership boards. Each of the boards haven’t got a clue on who delivers social care in their area.” (respondent)

What can be learned from examples of existing good practice in established ICSs?

This question was difficult for our respondents to answer as their involvement in ICSs was still new and the organisation’s themselves were new. However, there was reference to other regions where integrated care and health systems worked well, such as in Northern Ireland.

What scope is there for variation between ICSs, to enable them to improve the overall health of the populations they serve and tackle inequalities?

Our respondents said that by having the population health data and understanding what the data is telling you about different communities, this will enable targeted support for vulnerable groups.

How can it be ensured that quality and safety of care are at the heart of ICB priorities?

Our respondents were unanimous in suggesting that shared safeguarding and shared clinical practice would be two priorities for quality and safety. Some respondents felt that mandating quality and safety as part of ICB priorities was a way of ensuring that they are central to their focus.

How best can this be done in a way that is consistent with how providers are inspected for safety and quality of care?

There needed to be more of a focus on talking directly to providers and CQC and integrating the risk registers kept by CQC into their monitoring. There are already various monitoring systems for providers such as quality assurance monitoring by local authorities, regular CQC inspections and other contract monitoring by commissioning. There should be some integrated information sharing to prevent duplication and excess administration for providers and ICSs. Some respondents were in favour of ensuring that ICB members were from the frontline or were required to spend time within services on the ground to help their own understanding of safety and quality. There was a concern that the ICBs will become closed groups, detached from the realities and experiences of health and social care both from the perspective of those who work in those systems and from the perspective of people who receive care.

How can a focus on prevention within ICSs be ensured and maintained alongside wider pressures, such as workforce challenges and the electives backlog?

Our respondents were of an understanding that there are current resource constraints. This made it difficult to focus on prevention. However, prevention should for many, rest with adult social care. Some respondents felt that it was important for any strategy on prevention to use the structures that are already in place. Our respondents discussed the South Bristol Locality Partnership and how this represents what prevention looks like in a much more holistic way to include neighbourhood groups, voluntary groups and the community. They said the health of our community has to include ‘all of our issues’ and not just one provider or the NHS. This project went back to the point of using the population data and where there is the highest number of emergency admissions to hospitals and the highest attendances at GP surgeries and then looked at whole community responses.

“Start talking about community care, domiciliary care, live in care - those are the services more likely to deliver prevention than anywhere else.” (respondent)

Summary

Overall, there was a concern over the lack of involvement and coproduction with the social care sector.

Respondents were positive about the idea of ICSs but they were worried that in a way it is too early to see how accountability will develop at this stage. Current ideas of partnership working tend to leave out key stakeholders including representative groups of people who use services, carers and key parts of the provider sector such as homecare or care associations. This means that integration is very much health focused and true integration hangs on the ‘right spirits of hope and partnership’ rather than any tangible, measurable objectives of partnership. Currently providers were not seeing themselves being represented at the ICB level, but there is ‘hope’ that this will come in time. Finally, there were concerns that the very nature of ICBs were taking people away from the frontline and that there needed to be a clear and transparent link between ICB decision-making and experience and understanding of current frontline pressures for health and social care.

“I’ve been concerned that adult social care isn’t at the IC board level. Adult social care needs to be at all levels.” (respondent)

Aug 2022