ICS0030

Written evidence submitted by Barnardo’s

About Barnardo’s

Barnardo’s is the UK’s largest national children’s charity. In 2020/21, we reached 382,872 children, young people, parents, and carers through our 791 services and partnerships across the UK. Our goal is to achieve better outcomes for more children. To achieve this, we work with partners to build stronger families, safer childhoods, and positive futures. 

Barnardo’s works in partnership with ICSs, NHS Trusts, and Local Authorities to deliver commissioned integrated health and social care services for children, young people, and families. Barnardo’s delivers 157 health services across the UK[1]. These include delivering community-based social prescribing services to which primary care medical practitioners refer children and young people for non-medical, holistic, approaches to address health and wellbeing, Mental Health Support Teams in schools and specialist community mental health services. We deliver targeted therapeutic intervention and support for trauma, abuse and exploitation and work with children who self-harm, have substance misuse problems and neurodiverse children such as those with attention deficit hyperactivity disorder (ADHD) and autism. We also provide support for families, carers and new parents including practical public health advice on healthy lifestyles, oral health and breast feeding. We respond to this call for evidence in our capacity as a voluntary and community sector partner to ICSs.

Introducing Integrated Care Systems

Barnardo’s welcomes the development of Integrated Care Systems and their placement on a statutory footing within the Health and Care Act (2022). We believe that the core functions of an ICS are the correct areas for focus, and we welcome the emphasis on integration and collaboration.

However, there are several challenges facing ICSs for them to meet their aims, particularly for children and young people. The financial context in which ICSs are being established are creating difficult decisions and affecting service provision. Health and care services continue to be affected by the Covid-19 pandemic and its impact on staff and service delivery. Recovery is affected by historic spending inequalities across health and social care and between children and adult services. For example, less than 1% of the NHS budget is spent on children and young people’s mental health[2].

It is during childhood that the foundations of adult health are laid.[3] Children growing up in England today face some of the worst health outcomes in Europe, from poor nutrition and high levels of obesity to increasingly poor mental health.[4] Alongside this, we continue to see the increasing impact of climate change on children’s health, including increased air pollution.[5] In addition, children living in the most deprived communities face much poorer health outcomes than their wealthier peers. Many of these issues, if left unresolved, are carried into adulthood, with huge costs to our health and social care systems.

Local authority budgets have been cut significantly, with £249million of cuts to funding for children’s social care[6]. Research published by Pro Bono Economics this year, commissioned by children’s charities including Barnardo’s, found that in 2020-21 80.5% of local authority spending on children and young people went on such late intervention services – up from 58% in 2010-11. The remaining 18.5% of spending in 2020-21 went towards early intervention services like Sure Start children’s centres and family support. In 2010-11, early intervention services made up 42% of children’s services spending. Further cuts to spending are likely as inflation rises and the cost-of-living crisis begins to take effect. While ICSs may intend to invest in prevention, early intervention, and measures to reduce health inequalities, in practise this is likely to be affected by budget controls and the imperative of spending cuts.

The consequences of past and present funding pressures have led to increased demand for children’s mental health services, increasing accident and emergency presentations and pressure across the health and care service.[7]

A further challenge to the core functions of an ICS and their ability to deliver local responsibilities is the emerging conflict in relation to ICS priorities and national policy decisions. For example, Barnardo’s is concerned that the Health Disparities White Paper has been reportedly scrapped, when we know that a key goal of ICSs is to reduce health inequalities. Clear and consistent national leadership is important for ICSs to be able to effectively strategise and deliver their core functions regarding reduction in health inequalities.

Health inequalities will also pose challenges at a local level. ICSs cover variable geographies, population sizes and demographics. These factors affect the spread of ill health within an ICS, that may be difficult to measure and address at the scale of ICSs. This could result in underserved groups, including vulnerable children and young people being missed in assessment of need and provision of services, resulting in a failure to address health inequalities. Neighbourhood level working and partnerships with voluntary organisations, local leaders and community institutions would help to reach populations and better meet the needs of the most vulnerable.

Despite the pressures on ICSs, children and young people’s health and wellbeing must be a priority for all ICSs. Sending mixed messages to ICSs have the potential to lead to a postcode lottery in outcomes for the most vulnerable. Health inequalities and outcomes have their foundation in childhood. Improving population health and outcomes and addressing inequality begins with families at the point of conception. Early intervention is cost effective. Failure to act early for results in an annual spend of £17billion on preventable health and social care issues experienced by children, young people, and families[8].

ICSs, therefore, face financial challenges and difficult decisions. On a structural level they must also address the twin challenges of health creation within their populations and integrating health and care to build the most effective system possible. The current systems focus results in spend being weighted to late and crisis intervention and budgets on early intervention and prevention tend to be the areas that are squeezed. This is a false economy as we also need to build health among children and young people, intervening at an early age and stage of need/illness, to prevent them being the high need service users of the future.

Barnardo’s believes that some of the challenges detailed above can be tackled through effective partnership working, with the voluntary and community sector forming a key part of this. We currently deliver services within ICSs including mental health support teams, children’s centres, and support for young carers. Crucially we place the voice of children and young people at the heart of service design, delivery and evaluation.

We are also working with the Institute of Health Equity to deliver an ambitious health equity programme working with 3 ICSs to co-design a Children and Young People’s Health Equity Framework, with support from children and young people, and Voluntary Community and Social Enterprise (VCSE) partners in the ICS region.  

The Framework will be developed into a dynamic measurement tool which ICSs can use to gather the right information to focus ICS resource on the development of emotionally, mentally, and physically healthy children. The tool will provide a practical solution to addressing wider determinants of health, which lay the foundations of good health. Barnardo’s and the Institute of Health Equity will lend their expertise in developing supporting interventions to take evidence-based action on equity indicators[9].

Barnardo’s work with ICSs has led to several key learnings to ensure that children and young people receive integrated health and care support throughout ICSs and that their voices are heard and acted upon.

●       Start with a vision from perspective of children and young people 

●       Develop a clear set of principles for what it means to embed children and young people’s voice in decision-making and programme development

●       Define how system, place and neighbourhoods are meaningful to children and young people, how they need to interact and how strategic plans need to respond

●       Give equal priority to the twin challenges of health creation and service integration and optimisation

●       Determine priority shared outcomes for children and young people, and what this means for all partners

●       Identify which agencies children and young people are most likely to want to access support from, recognising different providers bring different skills & solutions

●       Seize the unique opportunities that ICSs create

These lessons rely on ICSs working with children, young people, families, and the services that advocate for them to embed coproduction from the earliest planning stages to service development and evaluation. This is important not just because young people, their carers and families have a right to be part of decisions made about them, but because co-production is core to expanding and strengthening service quality and effectiveness and because experiences of health, illness and care and treatment journeys add knowledge to improve services.

In embedding these voices through coproduction, Integrated Care System leaders and managers need to recognise that partnerships are supported and constrained in equal measure by the structures of an ICS. The model through which coproduction takes place can accommodate all of its value, or can increase boundaries or restraints for taking part, particularly for the most vulnerable.

Barnardo’s experience with coproduction is based on shared principles among partners, development of a shared vision and goals and mutual respect. Our work includes the pandemic-response programme See Hear Respond, which was delivered by over 80 charity partners and reached more than 100k children and young people. Young people are also brought directly into our central decision-making process through our B-Amplified model and our work in services such as HYPE (Helping Young People and Families Engage[10]) enables co-design and contributes to change in children’s health.

For ICSs to embed coproduction for children and young people, there must be an intentional focus on both organisational design and the embodiment of a co-production ethos. This will allow a real paradigm shift where equivalent value is given to the attitudes and behaviour of staff and shaping the culture in which co-production can thrive.

Recommendations

-          Government must publish the Health Disparities White Paper and provide national leadership on health inequalities

-          ICSs should partner with the voluntary sector to improve service design and delivery for the most vulnerable and underserved groups

-          ICSs should focus on children and young people’s health and wellbeing to tackle health disparities and ensure that this focus is reflected in ICS structure and strategy development

-          ICSs should consider the use of existing and developing frameworks to embed coproduction and the voice of children and young people in ICSs

-          There should be a ring-fenced fund specifically to aid the integration of health and social care for children and young people along the lines of the Better Care Fund which is mainly focused on adults

-         A Child Impact Assessment should be undertaken by the Government within two years of the Bill’s implementation to assess its impact on reducing health inequalities and health and care improvement for children.

October 2022