ICS0044

Written evidence submitted by District Councils' Network

About the District Councils’ Network

The District Councils’ Network (DCN) is a cross-party member led network of 183 district councils. We are a Special Interest Group of the Local Government Association (LGA) and provide a single voice for district councils within the Local Government Association.
Our member councils in England deliver 86 out of 137 essential local government services to over 22 million people - 40% of the population - and cover 68% of the country by area. DCN member councils have a proven track record of building better lives and stronger economies in the areas that they serve.
They protect and enhance quality of life and improve public health- through leisure and wellbeing service provision, their role as housing authorities, environmental health enforcement, benefits and welfare services, and safeguarding our green open spaces. District councils ensure no one gets left behind by addressing the complex needs of today whilst working to prevent the social problems of tomorrow.

Introductory Remarks on Districts’ Involvement in ICSs

Meaningful local government engagement is vital to achieve the systemic shift in the approach to health which underlined the introduction of Integrated Care Systems (ICSs). To meaningfully tackle inequalities in outcomes and access, the NHS and health partners needs to upstream preventative action alongside clinical care.
NHS providers can only directly influence the quality of, and access to healthcare. This only accounts for a small portion of the wider determinants of health. District council services like housing, leisure, customer services, environmental health, economic development, and planning are crucial factors which influence the good health of a community
These new systems must rely on districts’ expertise to deliver health priorities, or there cannot be an effective shift to a whole-system approach to improve community wellbeing.
This will require ICSs to meaningfully engage with district councils with true adherence to the principle of subsidiarity. Once local government is trusted to provide key services which improve health then ICSs will be able to deliver a truly collaborative, preventative health strategy.
For example, district councils’ housing and environmental health services are key system partners for the NHS which are key to facilitating the discharge of patients from hospitals. Councils are responsible for ensuring that homes are safe and administering the disabled facilities grants to adapt homes for residents living with long-term conditions.
In Leicestershire district councils are leading collaboration with the county council and NHS partners to identify barriers to discharge, then invest in low level adaptions which can facilitate a high-volume of patients returning to their homes. This can include undertaking minor repairs, negotiating with landlords, or overcoming wider issues impeding access to safe secure homes.
There are clear economic benefits from engaging with council’s current expertise and services to deliver a joined-up approach to public health, as modelled by The King’s Fund:[1]

The cost to the NHS of poor-quality housing is estimated by to be £2 billion per year.
The UK-wide impact of noise pollution alone is estimated to be between £2bn to £3bn per year, and food-borne illnesses cause around 20,000 hospital episodes each year.

Fields in Trust research has also indicated that frequent use of green spaces alone could save the NHS £111m per year in reduced GP visits.[2] The DCN’s ‘Fit for the Future: The Health Value of Wellbeing and Leisure Services’ report further indicated that every £1 invested in supporting local leisure services would deliver up to £23 in savings for the NHS.[3]
Without engagement with all tiers of local government, ICSs will not be able to deliver a truly preventative health strategy which addresses wider determinants of health which maximises existing resources.
Unfortunately, the engagement of districts in their locals ICSs throughout England has not been uniformly inclusive. In a survey undertaken in early 2022 when many ICSs were being meaningfully established, 32.5% reported little engagement and 10% reported no engagement or representation so far.
Districts are ready to deliver programmes addressing inequalities further entrenched by the pandemic, with and on behalf of our local NHS. We have the key knowledge and services to deliver a preventative health programme throughout England.
65% of our member councils indicated a clear lack of understanding from their local NHS services about the contribution which district councils can make to health services. Further integration of district services like planning, green space provision, and homelessness prevention is necessary for ICSs to pioneer early interventions which prevent illness for everyone in our society.
Our member councils played a vital role in spearheading the response to the pandemic in their communities, developing our position as the place leaders of choice in our communities. We can be a key contributor to improving health outcomes and have developed positive networks with hard-to-reach groups in our communities.
Many of our members indicate that engagement with their local ICS has been poor. Whilst 20% of our members reported having been very engaged in this implementation, only a further 37.5% reporting some engagement. This demonstrates the need for a comprehensive push for ICSs to engage with local district councils.
The impact of stress or uncertainty around finances and housing on individuals’ health is well document. As the authorities with the statutory responsibility for supporting our residents in difficult times, it is vital that district councils are involved in ICS decision-making to utilise our convening power.
In Lincolnshire for example districts are leading a cost-of-living project for their ICS, which is convening partners to identify collective action across the public, health and voluntary sectors to provide effective support for the most vulnerable residents. This underlines the critical role of districts in these partnerships to providing an all-encompassing response to the underlying factors affecting health in our communities.
Furthermore, over three quarters of our member councils indicated that previous positive relationships with other tiers of government or existing Clinical Commissioning Groups were crucial factors for meaningful involvement in the development of the local ICS. That this implementation has not reached out beyond the relationships and links from previous CCGs, demonstrate a failure in aspiration to maximise delivery against the objectives which underlined the creation of these new systems.
Districts have unique, vital expertise which can contribute to the improvement of overall outcomes and tackle inequality in said outcomes. The opportunity to engage with all tiers of local government remains and should be harnessed by ICSs to efficiently achieve their objectives.

What Can Districts Contribute to ICSs?

Many of the services which districts provide are clear assets to every ICS, with housing-related responsibilities being vital to address health disparities. The UK Health Security Agency (HSA) has highlighted the ‘critical role’ which housing quality plays in creating and maintaining good health, including allowing individuals to recovery from serious illness.[4]
The Building Research Establishment found in 2021 that the cost to the NHS of poor-quality housing was £1.4 Billion per year.[5] This echoes the HSA’s own findings from 2018 that the cost to the NHS of older people living in substandard housing was around £624 Million per year. This demonstrates a clear benefit to the NHS of joined up working with the local authorities responsible for investing and enforcing housing standards is clear.
Another example is the DCN’s recent Fit for the Future report which set out the concrete value for public health and the public purse that council leisure services can provide in engaging inactive members of our communities.[6]
This modelling indicated that by undertaking a comprehensive social prescription programme for leisure services- encouraging referral of 154 participants from each GP practice in England- would lead to key benefits for individuals’ own health, as well as significant savings for the NHS. These benefits, over a 10-year period would include:

Avoidance of over 44,000 diseases
A direct saving to the NHS of £314 million for the cost of treatment of those diseases
70,000 Quality-Adjusted Life Years (QALY) gained, with a health value of £1 billion and economic value of £4.2 billion
A 3.7 year reduction in the healthy life expectancy gap

This research demonstrates the benefits of collaborating with districts in just one of their services areas, delivering value-for-money for any investment in services whilst maximising existing infrastructure.
Often districts are presented with information on key health programmes system after the fact, representing a missed opportunity to engage those interacting with residents every day. District council services can not only provide unique insights into our residents’ lives, but also enable efficiencies for our health system.
Joined up collaboration between an ICS and the councils providing homelessness prevention services would help improve outcomes for our NHS by tackling problems at their root cause. County councils cannot represent district-level services, therefore if districts are not explicitly engaged with in two-tier areas, this limits the true impact which ICSs are designed to deliver.

Successful district engagement

To produce this response, we have engaged with our member councils who have been successfully involved with the new ICS structures in their areas. The examples set out below are not representative of all district councils’ experiences, as only a minority have been meaningfully engaged with. However, these represent good practice which should be proliferated throughout England.
One district in Oxfordshire reported that their local ICS has provided a forum for joined-up communication between partners. This means collaboration is much more efficient and has, in this case, removed the need to consult with each entity to deliver shared aims and programmes.
For example, discussions are currently underway to fund the expansion of an existing programme which helps patients with long-term conditions to better manage their symptoms through exercise.
In Lincolnshire there is very positive engagement with districts, with two district chief executives involved in the lead-officer group for the ICS and a district leader nominated to the Integrated Care Partnership board.
Officers have developed an action plan identifying districts’ contribution towards achieving ICS objectives, undertaking extensive engagement with all system partners. This plan sets out key actions from districts, such as delivery of housing objectives, economic inclusion and improving rates of participation in physical activity.
The plan relies heavily on districts’ expertise and experience with community engagement to achieve improve outcomes, tackle inequality and maximise productivity. Key actions identified by the plan are:

Improve supply, quality and coordination of services to meet housing needs and demands; this will work to ensure homelessness becomes rare, brief and non-recurring.
Leverage districts’ knowledge and connection with residents and places to improve access and opportunity for all residents to be active. This will be achieved by commissioning leisure facilities across Lincolnshire and protecting provision of parks and open spaces in communities.
Improve understanding of the links between the environment and health, maximising opportunities to deliver on both simultaneously. This will include working to improve air quality and encouraging residents to consider sustainable food options.
Reduce economic inequalities and alleviate poverty as a fundamental driver to improving mental health and physical wellbeing, by working with local employers and providing upskilling services for residents.
Leverage unique links to empower communities, building strong relationships with the VCS and community groups.

This demonstrates how districts can have an integral role in achieving ICS objectives, providing value for money for taxpayers by maximising their existing resources.
A key challenge identified by this, as with other districts’ experiences, is that there is currently no capacity to divert resources from the acute sectors of the NHS into preventative programmes. These sectors, alongside district councils, are experiencing significant financial pressures and a lack of workforce capacity.
This presents a challenge to not only preventative services but also to the resilience of all existing services. Additional investment is required to inject resilience into the sector, as well as to facilitate that each ICS can invest in preventative programmes that will improve outcomes for their communities.
District councils in Leicestershire have also been actively engaged in the implementation of the local ICS. This ICS recognises that district councils are key partners at a neighbourhood, place and strategic level.
For example, strong relationships with planning experts are recognised as important to preserve access to green space in order to improve residents’ health and wellbeing. This has also included relying on districts to contribute to the development of local growth plans to ensure that NHS services will grow to meet changing populations’ needs.
Districts have also been involved in the development of the needs assessment for their areas, as part of implementing a joint approach to health interventions. This is a key aspect of the implementation of the Joint Health & Wellbeing Strategy, helping to prioritise health interventions for communities throughout Leicestershire.
This further exemplifies the strength of integrating districts’ services to engage existing relationships and expertise, to improve outcomes throughout the ICS’ area of activity.

Conclusion

The introduction of ICS represents a systemic shift in priorities for the NHS which will entail an innovative approach to care. This will require the NHS to pool its resources & aligning strategy with key partners to tackle the causes of poor health, as this represents a realm of service delivery which ICSs will not currently understand.
Without involving districts in integrated care systems, it will be exceptionally difficult to address the wider determinants of health. Therefore, the benefits of engaging with Districts to collaborate to improve public health, by tackling the underlying causes of temporary ailments and long-term illnesses, are clear.
District councils have been serving their communities for decades, engaging with residents to understand their needs and combat entrenched inequalities. We have a plethora of expertise and infrastructure which is ready to feed to deliver our shared objectives.
The examples above underline the very positive contribution which districts are already making to addressing the wider determinants of health. The positive benefits already being delivered by councils administering social prescription pathways with health sector partners, demonstrate a positive path forward to improve residents’ quality of life and wellbeing.
Further investment must be injected into the health sector to proliferate this best practice throughout England, with this providing an impetus for all integrated care systems to harness the potential of collaborating with districts.

October 2022