Written evidence submitted by The Local Government Association (LGA)
Introducing Integrated Care Systems
The Local Government Association (LGA), as the national voice of local government, welcomes the opportunity to submit evidence on introducing Integrated Care Systems (ICSs).
The LGA has a long-standing commitment to supporting collaborative working between the NHS, local government, the community and voluntary sector, and citizens to improve services and health and wellbeing outcomes. Learning from local partnerships, we have identified several characteristics of effective partnerships. They are:
We developed the above principles with NHS Confederation, NHS Providers, the Association of Directors of Adults Social Services (ADASS) and the Association of Directors of Public Health (ADPH), drawing on our collective experience of working with effective local partners.
As well as working with national membership bodies, the LGA has also worked closely with the Department of Health and Social Care (DHSC) and NHS England on the formulation of guidance and resources to support the implementation of ICSs. This includes the Thriving Places pre-implementation guidance for ICSs on working at place level, and the engagement document on establishing ICPs.
It is important to note that over the past 10 years or so, there have been many different national initiatives to promote integration. ICSs are just one of the latest in a long line of Government initiatives to drive integration and collaboration. However, we do think the emphasis on partnership working with local government and the focus on improving population health represents a new approach to integration, seeing it as one in which all partners in a system have a role to play and one which is primarily focused on improving population health outcomes.
That said, ICSs, and their statutory components – Integrated Care Boards (ICBs) (which are statutory NHS bodies) and Integrated Care Partnerships (ICPs) (which are statutory committees of ICBs) are very new, only ‘going live’ on 1 July 2022. They will continue to develop and mature throughout 2022/23 and beyond. It is important that the Government and national organisations work together to support ICSs to promote a learning and collaborative culture in which ICSs can learn from each other, recognising that no two ICSs are the same. Through its legislative journey in Parliament, the LGA consistently supported the ‘light touch’ and permissive approach of the Health and Care Act 2022 to give local systems the flexibility to make their own arrangements for joining up services and set their own priorities and strategies for improving population health.
Improving outcomes in population health and health care and tackling inequalities
In principle, we support the proposed national shared outcomes framework in the Integration White Paper, published in February 2022. The LGA is committed to working with DHSC and other stakeholders to develop a small set of high-level national outcome measures. We recognise that the Government and their agencies lead the policy agenda for ICSs and as such, it is appropriate that they set a small number of high level and strategic targets for ICSs. However, these targets should be focused on outcomes rather than process or activity. For example, setting targets for addressing health inequalities, to improve health and wellbeing outcomes, to improve access to health, care and wellbeing services and support. Given the recent political uncertainty and change, it is perhaps not surprising that progress on developing a shared outcome framework has been slower than anticipated. We will continue to work with Government to ensure that any new national outcome measures are helpful, proportionate and based on information already available to local systems.
Each ICB is required to publish an annual report on how it has discharged its functions in the previous financial year. It must also report performance on the forward plan and on the capital resource use plan. Each ICB must review what has been done to implement all relevant joint local health and wellbeing strategies (JLHWS) and consult with each relevant health and wellbeing board (HWBs) on this review. It must also review the extent to which it has exercised its functions consistently with NHS England’s views about how powers in relation to information on inequalities. We consider this provides adequate accountability to NHS England while still allowing the ICS the flexibility to address local priorities, including health inequalities.
That said, ICSs are diverse in terms of their size, demography, health challenges, configuration of services and as such, they require the flexibility and freedom to identify their own targets for improving population health outcomes. It is equally important to recognise the diversity within ICS footprints, especially in the larger ICSs. ICSs will need to recognise and support place-based leaders to identify their own priorities and set their own strategies for improving population health outcomes.
A rigid national template for how all ICSs should seek to improve population health and health inequalities simply would not be achievable or helpful. However, we should aim to minimise the variation in terms of access to services, support and treatment. But even in this respect, there will need to be local variation in the way in which services are accessed and delivered, for example, there are inevitably differences in access to services and support between rural and urban areas.
In addition, all ICSs have different starting points for the health challenges of their populations and the progress they have made so far in joining up care and support for people. There will, inevitably, be variation between ICSs but all should aspire to make demonstrable improvements in improving services, addressing health inequalities and improving population health outcomes.
Finally, there is already huge variation in the NHS in terms of access to services, service quality and outcomes. ICSs need to be clear about the reasons for this variation and, where it is unwarranted, to learn from other ICSs that have smoothed variation. ICSs will need to be transparent and accountable to local people and to partners, as well as accountable to NHS England and upwards to Parliament for broad national priorities.
At this stage of their development, it is difficult to ascertain whether there is the right balance between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for achieving national priorities. ICSs are a significant and - in our view -welcome departure from the national top-down approach to NHS accountability and priority setting. However, there is still clear ICB accountability to NHS England. The LGA has long argued that the NHS needs to be accountable to its local population for achieving priorities of most importance to local populations.
It is important that national and local partners see 2022/23 as a transitional and learning period in which all leaders across the NHS and local government are committed to learning from experience, sharing good practise and, if necessary, revise guidance and support available to ICSs for them to maintain the balance between having the flexibility to respond to local challenges and be accountable for them local, while still providing accountability at national level for achieving national priorities.
Helping the NHS support broader social and economic development
The LGA supports the ‘fourth objective’ of the NHS Long Term Plan, for the NHS to support broader social and economic development, in recognition of the contribution that NHS and adult social care organisations make to local economies. There is a growing appreciation of the role that individual NHS trusts are able to play as anchor institutions: their size, workforce, procurement budget, environmental impact, social and civic power gives them the ability to have a significant influence on local economic development and prosperity.
The NHS’ role as a provider of healthcare services can also have an impact on local economies. Ill health affects people’s participation in the labour market, with over 300,000 people annually falling out of work and onto health-related welfare. Helping people with health issues to obtain or retain work and be happy and productive within the workplace is a crucial part of the economic success and wellbeing of every community. The NHS needs to work with local government to join up health and employment support systems to help those with health issues to obtain or retain employment. Doing this will result in both improved health outcomes but also economic gains as having one extra disabled person in full-time work, rather than being out of work longer term, would mean Government could save and re-invest £15,000 a year.
The ability of the NHS to shape economic development and drive local growth is therefore significant, but they will only achieve partial success by working alone. We know that where devolution of health and social care has taken place, areas have seen significant benefits for local residents. For example, the Greater Manchester Population Health Plan update showed a substantial increase in school readiness and a smoking prevalence rate falling twice as fast as the national average. ICSs can work closely with local authorities to support local authorities in their role as leaders of place, planning, community development and resilience, as well as their role in supporting local people into work.
There are existing initiatives, such as ‘One public estate’ which are led by local authorities and aim at joining up the public sector to make the most of its collective assets, for example ensuring that use of public estates contributes to local priorities such as expanding the affordable housing stock to support key workers, but there is much more that could be done if central Government made it easier for the NHS and local government to align investment and priorities. This would support both improved health outcomes and improved economic growth. The roll out of ICSs must not diminish the role that local authorities already play in driving growth and supporting economic and social development, but enable the NHS to support existing work and complement it.
Enhancing productivity and value for money
We need to learn from previous integration initiatives to understand better how they can improve productivity and value for money for the health and care system as a whole. The evidence on how ICSs will do this is currently very slim. This is because ICSs are new organisations and a new way of working. It is important that we support them to understand how they can learn from best practice.
The aim of joining up health and care is to ensure that people have the support they need to improve their health, wellbeing and independence. The aim is to reduce their dependence and maximise their independence. The focus on prevention and early intervention is welcome – it aims to provide community based services that reduce the need for higher intensity, higher cost health and care services.
We encourage the continued focus and investment in recovery services such as reablement, which are proven to provide return on investment of between five and 13 times, and continued support for Home First approaches which support more people to return home after a hospital stay, where recovery is faster and better.