ICS0025

Written evidence submitted by NSPCC

The NSPCC is the leading children's charity fighting to end child abuse in the UK. We help children who have been abused to rebuild their lives, protect those at risk, and find the best ways of preventing abuse from happening.  At the NSPCC we know that the health and care system has a crucial role to play in meeting children’s needs, preventing abuse and helping children recover from traumatic experiences.

Introduction and summary

The needs of babies, children, and young people must be at the heart of integrated care systems (ICSs). It is for this reason that the NSPCC and other organisations working together as part of the children and young people’s Health Policy Influencing Group[1] successfully called on the Government to give children a greater focus in the Health and Care Act. As a result, Integrated Care Boards (ICBs) are required to include children in their forward plans and will be required to appoint an executive lead for children and young people. NHS England are to issue guidance on ICBs’ safeguarding duties, and the Department for Education is required by law to publish a report on information sharing on children’s issues.

The NSPCC welcomes the Public Accounts Committee’s Inquiry into the implementation of Integrated Care Systems. We believe the Inquiry presents the opportunity to help hold Government accountable for delivering on these commitments made in relation to children.

Issues have already arisen. For example, despite ICBs already being established, our desk-based analysis of publicly available information on ICB websites between 1 July 2022 and 11 October 2022 has found evidence that suggests only a third of ICBs have appointed Executive Leads for children so far.[2] This issue is compounded by, and potentially a result of, a failure on NHS England to publish statutory guidance on these roles.

Specifically, the NSPCC is asking the Committee to:

• Monitor the development of Department of Health and Social Care guidance for Health and Wellbeing Boards (HWBs) to ensure they direct HWBs to inform ICBs of the needs of babies, children and young people;
• Investigate the delay in publishing guidance from NHS England on ICB’s Executive Lead responsibilities and to press for the guidance to be published as soon as possible – at latest by the end of the year;
• Consider revisiting the implementation of ICSs and the Health and Care Act in early 2024, when more duties in relation to children and young people are due to be in effect.

Children in the Health and Care Act 2022

The transition to ICSs provides the opportunity to secure the delivery of joined up services for babies, children, young people and their families. For this reason, the NSPCC alongside other children’s organisations[3] called on the Government to ensure children were better recognised in the Health and Care Act 2022. As a result, several key commitments were secured:[4]

1.       ICBs are required by the legislation to set out steps they are taking to address the needs of children in their forward plan (making children and young people one of only two groups singled out within the primary legislation in this way)[5]

2.       Integrated Care Boards will be mandated by statutory guidance to nominate an Executive Lead on children and young people with responsibility for championing the needs of babies, children and young people under the age of 25[6]

3.       NHS England will issue statutory guidance on how Integrated Care Boards should fulfil their statutory safeguarding duties and requiring them to report annually on how they are fulfilling these duties[7]

4.       The Department for Education is required by the legislation to publish a report (before July 2023) on government plans to improve information sharing for the purposes of children’s health, social care and safeguarding[8]

Babies, children and young people at the heart of ICSs

It is right that these amendments and commitments place children and young people at the centre of ICSs. It is now vital that the set-up of ICSs and the implementation of their strategies and workplans reflect these commitments and obligations and for ICBs to fulfil their duties with regards to children and young people.

Integration and joint working are crucial to improving outcomes for babies, children and young people. The Office for Health Improvement and Disparities published ‘Babies, Children, Young People and Families in Integrated Care Systems’ in May 2022. The document rightly states that “the transition to ICSs presents a huge opportunity for local health and care leaders to work in partnership on the planning and provision of services, to make sure they are more joined up and better meet the needs of Babies, Children, Young People and Families”.[9]

In order for the transition to be successful, there must be a strong focus on babies, children and young people at all levels of an ICS, including ICBs and Health and Wellbeing Boards (HWBs). Children are a distinct population who use a distinct health and care system with its own workforce, legislation and integration challenges. Every family will come into contact with a range of different health and care services including maternity, health visiting and early years, and may also engage with children’s social care, mental health and paediatrics.

Successful integration improves information sharing and reduces the need for families to repeat their stories to multiple agencies. There can be strict criteria for services, as each service has its own priorities and budget to protect. This means that families can fall through the gaps if they are referred from one service to another but then do not meet the threshold for support. Better integration of services would provide a fuller picture of families’ needs and enable different professionals to work together to safeguard children, flagging any concerns and risks with each other. The Government has recognised the importance of integration of services for children and families within health and care systems in their Best Start for Life programme,[10] and the House of Lords Public Service Committee stated it was crucial to the success of the Family Hubs programme.[11]

Successful implementation of the child-facing commitments made by the government within and in relation to the Health and Care Act is the minimum required to deliver the integrated system that babies, children and young people need. Currently, draft guidance behind HWBs does not have sufficient focus on children and young people, and statutory guidance on the Executive Leads on children and young people on ICBs is yet to be published. This means there is a risk that children’s needs are not adequately considered or met in the implementation of ICSs and targeted action from government is needed to address this risk with required guidance updated and published. The Public Accounts Committee can play an important role in holding government accountable for these actions, including revisiting the implementation of ICSs next year when more duties in relation to children and young people are due to have come into effect.

Children in forward plans

Under the Health and Care Act statutory scheme, before the start of each financial year, each ICB and their partner NHS trusts and foundation trusts must publish a five-year Joint Forward Plan.[12] This must set out how they propose to exercise their functions, including proposals for health services, and action on the ICB’s general duties and financial duties.[13] Plans must describe any steps taken to implement relevant joint local health and wellbeing strategies,[14] to address the needs of children and young people under 25, and to address the needs of victims of abuse, whether adult or children.[15] The ICB and its partner trusts must have regard to the plan.[16]

Established and hosted by local authorities, Health and Wellbeing Boards (HWBs) bring together the NHS, public health, social care and elected representatives, to plan how best to meet the needs of their local population and tackle local inequalities in health. The Department for Health and Social Care ran a consultation on draft updated guidance to reflect HWBs’ role within ICSs.[17] The draft guidance sets out the importance of HWBs in informing ICBs and their Joint Forward Plans with localised knowledge. The Integrated Care Strategy must also place consideration on the Joint Strategic Needs Assessment (JSNA), a responsibility of HWBs. Bearing this in mind, HWBs could (and should) provide insight into the distinct demographics, circumstances, and issues faced by children in accessing services locally; local social determinants of inequalities in child health such as poor housing or poverty; and the thoughts, opinions and voices of children and families through the local authority’s experience of public engagement.[18] As a board of a local authority, HWBs are also well placed to directly involve children’s social care in their work.

Currently, the draft guidance for HWBs lacks substantive reference to babies, children and young people, creating a missed opportunity to prioritise their needs within the new system. Whilst the guidance states that HWBs should consider groups who might be excluded from engagement, including children and young people,[19] there is no requirement that children and young people should be directly included within their considerations and local needs assessment. We recommend there should be.

In addition to being more explicit on the needs of babies, children and young people, the guidance should also be more direct in encouraging HWBs to include representatives from children’s social care in their membership. The guidance currently includes representatives from children’s social care as optional attendees and members, outlining that “HWBs can […] at their discretion” invite organisations from children’s social care.[20] Considering the value of ICBs in obtaining local intelligence from HWBs, the guidance should set an expectation that HWBs include representatives from children’s social care as an important way to capture the local need of babies, children and young people on an ongoing basis, rather than merely suggest it as an option. 

Ask of the Committee:

• For the inquiry to monitor the development of guidance behind Health and Wellbeing Boards to ensure they direct HWBs to consider the needs of babies, children and young people and include children’s social care in their membership. Without such changes, there is a risk that ICBs will not receive important information about children’s health and care needs.

Executive Leads in ICBs

The role of Executive Lead for children and young people (ELCYP) is crucial in ensuring that the needs of this population are adequately addressed and focused on at ICB level. It is for that reason the Government committed to the publication of statutory guidance around this executive role which directs every ICB to appoint such a lead. However, despite ICBs being in operation since 1 July 2022 there has been little progress in updating national guidance to ensure that these roles are fully introduced and meaningfully established, thus resulting in a mixed picture across the 42 ICBs.

Guidance to clinical commissioning groups on preparing integrated care board constitutions, published in May 2022, stated: “During the consideration of the legislation, parliamentarians made clear that they wanted to see clearer executive leadership on certain issues. The government and NHS England agreed that ICBs will be required to identify named executive board member leads for safeguarding and special educational needs and disabilities (SEND), and for children and young people’s services. These are not new statutory duties or additional board posts, but rather intended to secure visible board-level leadership of these issues.”[21]

The lack of updated guidance could contribute to a number of issues in relation to this direction and the work of ICBs. Firstly, the NSPCC’s desk-based analysis of publicly available information on ICBs suggests a small proportion of ICBs have appointed ELCYPs with only 1 of the 42 ICBs looked at by the NSPCC referring to the post within their constitution. At the time of writing, ICBs have been in operation for over three months, with minutes from meetings publicly available. In analysing the publicly available minutes of all ICBs between 1 July 2022 and 11 October 2022, NSPCC analysis found only a third (33.3%) referred to the appointment of an ELCYP.

Secondly, without detailed and properly promulgated guidance in place, there is the risk of a lack of clear responsibility for CYP issues at ICB level. For those that made no direct reference to an ELCYP, there were instances where non-ICB member individuals presented work in relation to children and young people. Although there was welcome evidence within minutes of ICBs holding detailed discussion of CYP issues, such work and information sharing could be lost if someone at executive level is not ultimately responsible for actioning issues raised. For those ICBs that did mention the existence of an ELCYP, there were great levels of disparity in who held the role and what their responsibilities were. For example, across some ICBs, the individual holding this responsibility also had other wide-ranging roles and responsibilities. Without the publication of guidance and expectations of the role, the Board-level focus on CYP could be lost. 

Thirdly, at this stage, information on appointments and responsibilities at ICB level was often hard to obtain, and appointed ELCYPs were often not clearly signposted. This makes it harder for those within an integrated care system, including children’s services, children’s social care and HWBs, to easily understand their local healthcare system and to whom they should communicate relevant issues. It also means that the new healthcare structures lacked transparency in relation to governance.

It is imperative that published guidance directs the ELCYP to have a broad focus in relation to age groups and specifically consider the needs of babies and infants as part of their operational responsibility for ‘child and young people’. Gaps in outcomes between babies are broad and deep and can lay the foundations for lifelong health inequalities. Babies are also more likely than older children to experience significant harm.[22] For these reasons, ICBs must specifically consider babies needs, and work to ensure join up with related government programmes such as the Best Start for Life vision[23] and Family Hubs.[24]

It is imperative that the long-awaited guidance for the role of Executive Lead for children and young people is published and rolled out across ICBs, with follow-up monitoring to ensure that all ICBs comply with this duty. Without this guidance, some ICBs will continue to operate without having appointed this role, whilst others may not fully understand the purpose and function of the role.

Ask of the Committee:

• For the Inquiry to investigate the delay in publishing ICB guidance from NHS England on Executive Lead responsibilities and to press for the guidance to be published as soon as possible to make sure that there is no further delay in the rollout of ICB Executive Leads for children and young people.
• For the Inquiry to press for specific inclusion of babies and infants within guidance around the Executive Lead
• For the Inquiry to press the importance of ICBs being transparent, providing clear and accessible information for their communities.

Ongoing scrutiny

As stated above, ICBs are required by the Health and Care Act to use their forward plans to address the needs of children (the first to be published April 2023), while the Department for Education are obliged to publish a report on plans to improve information sharing for the purposes of children’s health, social care and safeguarding by June 2023. NHS England is also to issue statutory guidance on how ICBs should fulfil their statutory safeguarding duties and require them to report annually on how they are fulfilling these duties. 

As the ICSs continue to embed, and with many of these responsibilities coming into effect across 2023, the NSPCC believes it is crucial for the inquiry to revisit this matter in early 2024. This would also gather evidence that could inform the next spending review due in 2024 if resourcing issues are identified. The Health and Care Act rightfully placed children and young people at the centre of reform, recognising the importance of integrated care for this population. However, unless these commitments are fully and properly implemented, progress will be limited.

Ask of the Committee:

• For the Inquiry to consider revisiting the implementation of ICSs and the Health and Care Act in early 2024, by when more duties in relation to children and young people are due to have come into effect

October 2022