Written evidence submitted by Health Devolution Commission (ICS0066)
A) The Health Devolution Commission: an overview of its approach
The Health Devolution Commission is an independent cross-party and cross-sector body working to champion and support the successful implementation of devolved and integrated health and social care services across England. It was established in 2020. Its Co-chairs are the Rt Hon Sir Norman Lamb and Rt Hon Andy Burnham. Further details are available on the Commissioners, Partners and previous reports – please see www.healthdevolution.org.uk
The Commission has long believed that the lack of local integration between the NHS and social care, public health and other local government and public sector services, is a major barrier to improving people’s health outcomes, improving the experience of care that people receive, reducing health inequalities and improving the public’s health. As well as the economic and social costs to the health and prosperity of local communities this lack of integration creates avoidable cost inefficiencies.
The Commission therefore believes that the successful devolution and integration of health (physical and mental), social care and public health will enable frontline staff to better meet the needs of local people, families and communities; provide a better, seamless experience of care; improve the public health and economic wellbeing of local communities; help reduce health inequalities; and support the financial sustainability of local services.
The Government’s proposals for health and care integration in the White Paper ‘Joining up care for people, places and populations’ are largely welcomed by the Health Devolution Commission. It represents the paradigm shift called for by the Commission, among many others, to move the NHS towards a fundamentally new purpose and a genuinely new partnership with Local Government, the Voluntary Community and Social Enterprise sector, and the local communities that it serves.
In particular, the Commission supports the development of place-based shared outcomes to drive integration; joint leadership, accountability and finance; common digital and data systems; and integrated health and social care workforce planning. It also supports the view that integration is not just about delivering better person-centred care but also about improving the public’s health and reducing health inequalities. We applaud, for example, the White Paper’s call on people to ‘think housing and community’ when they develop their local partnerships and strategies.
The development of statutory Integrated Care Systems is therefore welcomed by the Commission. Working with its partners - the LGA, the NHS Confederation, London Councils, BACP, Barnardo’s, Mencap, GM Health and Social Care Partnership and WY Health and Care Partnership – the Commission is working directly to help make ICSs a success through collating, collaborating and sharing thought leadership and expert opinion on devolution and integration from a broad range of perspectives, providing examples of best practice and influencing government and NHSE guidance.
The Commission recognises, however, that whilst it is ambitious for ICSs to achieve their potential there are significant challenges as statutory ICSs seek to implement new approaches including new and multiple accountabilities. These include:
The Commission however has some concern that nothing fundamental might change unless there is a real drive and desire to take advantage of the opportunity ICSs present to do things differently. In part this will depend on strong encouragement from the centre (Ministers and NHSE) to be radical.
B) Answers to specific questions posed by the Committee
The Government has made a fundamental legal shift from competition to collaboration as the organising principle of the health and social care system. It has supported the implementation of this principle through the creation of an entirely new sub-national 3-tier partnership delivery structure of Integrated Care Systems, place-based boards and neighbourhood primary care networks. And it has spelled out the four broad shared aims this new delivery structure is designed to achieve, namely to:
To be effective and successful, this very welcome system transformation requires an entirely new approach to the balance between local and national accountability and autonomy within and between the health and social care system at every level. It requires a concomitant shift from an accountability system based on hierarchy and instruction from above, to mutual accountability based on local networks, collaboration and partnerships within a national framework.
Specifically, the legislation for transformation of the health and care system means that Integrated Care Boards should not, as before, ‘look up’ for instruction and permission to move. But rather, to ‘look out’ and fully and formally collaborate with organisations which are locally democratically accountable. In effect ICBs, like their place-based boards, must now perceive themselves as being primarily accountable to the geography of their system and no longer accountable only to the bigger NHS region (and through them nationally to NHSEI and the DHSC) in which they happen to sit.
This new balance between ‘vertical’ and ‘horizontal’ accountability requires the NHS and local partners to develop a new culture of partnership working and mutual accountability for shared outcomes; new collaborative processes and structures; and a new transparency in the way decisions are made. These are already apparent in some systems and the move must be supported by changes in the way NHS England and national agencies work.
Vertical/national accountability in the transformed system is still, of course, required in some form but crucially is now only one element in a system of governance that must have an appropriate balance of multiple accountabilities. If not, then nothing will have fundamentally changed and the new legal purpose and structures of the reformed health and social care system will be fatally undermined.
Getting right the nature and balance of that national, local and new accountabilities within a system of multiple accountabilities requires fresh thinking, and the Health Devolution Commission has identified five key elements that should change:
This needs to go beyond including representatives of patients, the local HealthWatch or mental health service users on an ICP – although doing all three would be good practice. They should proactively engage with communities in their ‘place’ with a clear set of principles for embedding the public voice and a particular focus on underserved groups and those with additional communication needs. This should be supported by a definition of how system, place and neighbourhoods are meaningful and some clear guidance for engagement. In addition, ICSs should ensure it is working in a spirit of partnership with voluntary and community sector partners and a charter detailing how this will take place in practice should be agreed.
5(i) It is important that the public within an ICS area know “where the buck stops” – whom is responsible locally if, for example, there is a critical error in delivery or planning of services, or both? The relationship between the ICB and the ICP - and specifically the roles of the chairs and chief executives of the ICB and ICP - therefore need to be clear, agreed and well known.
5(ii) The IC Board Plan should be openly and democratically scrutinised through existing local authority systems on whether it sufficiently meets four criteria: does it reflect the integrated care strategy; is it financially viable; is it consistent with the commitment to reducing health inequalities; and does it reflect local population priorities?
5(ii) Given the primacy of place-based partnerships and that these will (generally) be chaired by a local authority leader, democratic accountability at the place-based level is relatively clear.
A permissive framework for ICSs - that supports maximum flexibility for local partners to establish priorities, populate appropriate governance structures, design funding flows and budgetary controls and so on - is necessary to achieve their new legal purpose and to redesign the health and social care system.
The shift from competition to collaboration as the organising principle of the health and social care system requires a new culture of partnership working and mutual accountability for shared outcomes; new collaborative processes and structures; and a new transparency in the way decisions are made. Crucially, attention to all of the four primary aims of ICSs will be key to driving this new paradigm of health and wellbeing.
Place-based collaboration will require partners to agree shared values for working together, build trusting relationships, develop a joint learning culture, and adopt a performance development approach to service improvement. NHS, Local Government and VCSE sector leaders should be exemplars of this new culture of collaborative behaviour.
The nature of national performance targets must change with more emphasis on national quality standards whilst decisions are made locally on how they are met. The role of the centre should also change to that of supporting local systems to set local performance targets and priorities that clearly reflect the needs and circumstances of their populations and services.
A specific set of shared outcomes for the system to achieve may be best structured around a Life Stage approach such as ‘Start Well, Stay Well, Age Well’, which clearly also reflects local population health inequalities. The focus on place is at the very heart of the new system, with the aim of maximising delegation of the ICS non-hospital spend to place-based partnerships responsible for delivering the shared outcomes (as local circumstances allow).
It is important to note that ICBs have replaced an existing layer of bureaucracy. For example, in Greater Manchester, the ICB has replaced 10 CCGs, replacing fragmented bureaucracy with unified bureaucracy. Furthermore, ICS are not part of NHS England, they are separate statutory organisations operating within complex adaptive systems. They mut be treated as such and not as a layer of bureaucracy.
However, it is the case that ICBs may come to be seen as an additional layer of bureaucracy if central targets are not reformed. If they are left in place, the current system will fatally undermine the new legal purpose and structure of a system based on collaboration and partnership and rooted in place.
It is a case of not just reducing or amending the nature of national targets but establishing a wholly different relationship between the national partners and the new 3-tier health and social care system affecting targets, financial flows, budgetary controls, accountable officers and so on.
The Commission has during 2022 heard evidence of emerging good practice related to improving accountability including:
Health in All Policies: A ‘Health in All Policies’ approach must be adopted by ICSs to tackle the social determinants of ill-health if there is to be a significant reduction in health inequalities. This approach is being developed at every level - local, city, region, national and supra-national - and emerging evidence from Coventry and Greater Manchester shows that it works. But much more must be done nationally in the UK, underpinned by law, to reverse the last decade’s shocking decline in health equality if ICSs are to succeed in this goal.
ICSs as Community Anchors: Large hospitals are increasingly recognising their role and impact as anchor institutions in local communities, and want to work in partnership with local government, the voluntary sector and local businesses to address health inequalities in the population as well as addressing inequalities in access to health services. ICSs should ensure that every hospital adopts this approach and develops their role as anchor institutions in the community
Equality and Quality: The goal of equality as well as quality should be embedded in ICS and organisational codes of governance, and clear evidence shown that institutional resources are being shifted upstream towards prevention and health creation. The ‘bottom-up’ voice of communities, including the VCSE, and ‘top down’ action by system leaders should be combined to crack the challenge of improving the population’s health and reducing health inequalities through integration and health creation.
National Leadership: The landscape for children and young people is more complex for ICSs to manage as it includes education – schools and academies – as well as the NHS, local government and the voluntary sector. Effective data sharing is still not in place and there are no dedicated national funding streams for children’s health as there are for conditions such as cancer. National cross-departmental leadership between health, social care and education is required to support the co-production of a CYP health care framework and integrated action at the level of the ICS, place and neighbourhood levels.
Leadership: Mental health services should be represented at every level in the ICS system with a full place on the ICS Board. There should be a process to allow the voice for mental health service users to be heard at every level - the ICS, place-based partnerships and Primary Care Networks. In addition the Integrated Care Board member for Learning Disabilities and Autism should use their position to request regular reports on the delivery and impact of the Learning Disability Register, Annual Health Checks and Health Action Plans as a means of influencing the system.
Each ICS will have a unique profile of its population’s health needs and inequalities that will require a tailor-made improvement strategy that reflects their local circumstances and context. Consequently, variation between ICSs in their strategies to improve population health and reduce health inequalities should be regarded as a measure of their success.
However, all ICSs should be expected to adopt measures that are properly evidence-based and have the active support of all partners. This should include robust population health and clinical data; be sufficiently granular to identify localised places or communities experiencing health inequalities; draw on professional knowledge and insights; and use real-time data that is cost-effective to gather.
The goal of equality as well as quality should be embedded in ICS and organisational codes of governance, and clear evidence shown that institutional resources are being shifted upstream towards prevention. The ‘bottom-up’ voice of communities and ‘top down’ action by system leaders should be combined to crack the challenge of improving the population’s health and reducing health inequalities.
Central to this is disaggregation of targets. By almost every measure, people in deprived populations, those who are vulnerably housed, those with mental health and learning disabilities and people from specific ethnic communities fare worse. This must be addressed, building on the excellent work in the CORE20 PLUS 5 national work.
Quality and safety of care must be at the heart of the priorities of ICBs, place-based partnerships and neighbourhood primary care networks. Equality should be viewed as a key element of quality and as such be explicitly embedded in the priorities of the ICS at every level. These priorities must be reflected in the strategies and governance mechanisms of these system structures as well as being a routine feature of service providers systems.
In addition, safety remains a feature of accountability in all of the organisations that make up the ICB. Good organisations in a good system are prerequisites of a safe, high quality service.
Central to achieving the goals of quality and safety of care are having sufficient staff, sufficient resources and good regulation of both.
Fundamentally, providers are part of a system – the ICS – and their inspections should take into account their duty to collaborate and their quality of services. The ICB inspections should draw on all of the provider assessments within a place and focus exclusively on the role of the ICB.
The Commission will hear from both the CQC and Ofsted at its meeting in September 2022 about their respective approaches to the inspection of service providers and system structures. Issues being further considered will include:
The first and second primary aims of ICSs require an unrelenting focus on prevention if the third aim of enhancing productivity and securing value for money is to be achieved. The current pressures on the NHS must be addressed as a matter of urgency and this will require immediate additional funding.
At the same time, there must be an expectation at every level that the health and social care system will develop new policies and strategies that focus on prevention and reshape services and re-allocate resources towards that goal.
Whilst the focus for this will be at the sub-national level (ICSs, place-based boards and neighbourhood primary care networks) this must be reflected at national level in new joint policies and strategies by DHSC and DLUHC.
National messaging, incentives, planning and management must reflect the need to focus as much on prevention as wider pressures. This is not always the case. In particular, OHID, the levelling up agenda and DLUHC will need to contribute alongside DHSC in policy and support for delivery. Immediate support for local government is key.
It will be important for the Government to recognise that for ICS to be successful in their primary task of reducing health inequalities it has a responsibility to undertake complementary activity. For example, if child poverty increases, better health outcomes for children will be impossible for ICSs to deliver.
Aug 2022
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