The Health and Care Act 2022 provides a legislative framework to support closer integration of health and care. It has put integrated care systems (ICSs) consisting of an integrated care board (ICB) and integrated care partnership (ICP), on a statutory basis. This dual structure is a new approach and intends to address concerns that an ICS would be unlikely to act effectively as both the body responsible for NHS finance and performance, and as the wider system partnership. However, questions remain regarding the precise relationship between the ICB and ICP, as well as the non-statutory place-based partnerships which sit below them - and how they will relate to each other in practice.
Rather than being an end point, the passage of the 2022 Act marks a new chapter in the integration journey – a new opportunity. Even before the Act had passed, the government published a further White Paper, Health and social care integration: joining up care for people, places and populations (the 2022 White Paper) which stated the aim to go ‘further and faster’ with integration. The White Paper poses many questions reflecting the challenges remaining at ‘place’ level. Many of these questions relate to outcomes, accountability and finance arrangements, all of which are key components of good public financial management.
CIPFA will address these challenges in greater detail in a forthcoming publication.
The term ‘integration’ has been used in relation to health and care for many years, yet still it seems to mean different things to different people and questions remain on exactly what it is seeking to achieve. Over time, there appears to have been a widening of the scope in integration policy, from closer integration within the NHS, and between the NHS and social care, to a much broader view encompassing the wider determinants of health and wellbeing to have a positive impact on population health management, with a focus on prevention and reducing health inequalities. This is reflected in the triple aim within the 2022 Act.
Partners across systems/places should embrace the opportunity to truly work differently. Taking a more strategic, long-term and place-based approach encompassing the social determinants of health and wellbeing, reducing inequalities and with a focus on prevention could make a huge contribution to achieving the core purposes of ICSs and the triple aim duty, while helping to ensure that health and care services remain sustainable for future generations.
The experience of the COVID-19 pandemic has brought the issue of health inequalities into sharp focus. However, evidence suggests that improvements in population health have been in decline for some time. The causes of poor health and disease are influenced by more than just the healthcare system. Wider social determinants of health have been suggested to have a greater impact on health and wellbeing outcomes than health services themselves.
However, when it comes to influencing the social determinants of health and wellbeing, the role the NHS can play is limited – it simply does not hold the required levers. Also, the health and wellbeing need of the population, and associated service pressures, are not homogeneous. Different areas have different needs based on their local circumstances. It is essential that wider partners, who can understand and influence the health and wellbeing of the local population, are equally engaged in policy and planning and that a more joined up ‘whole system’ approach is taken.
The 2022 White Paper took a welcome emphasis on ‘place’ as the engine room for integration and recognised the key role of local government as equal partners, although it continues to refer to local government as a whole.
All levels of local government have a key role to play in influencing the wider determinants of population health and wellbeing, as well as a deep knowledge of their places and neighbourhoods. Therefore, it is crucial that both upper and lower tier councils are engaged at the level of place and in the ICP.
Given the way in which ICSs have evolved at different rates and in different forms, it is unsurprising that not all ICSs are equal – there is considerable variation between systems, and even between places within a single ICS. This variation arises from a number of factors - including geography, demography, partners and the co-terminosity between them and maturity of relationships/collaboration.
All of these factors will therefore play into the nature of the system and its places, as well as the extent to which functions (and resources) are delegated. The ‘maturity’ of a place may not be the only factor involved in making a decision on delegation of functions. For example, in some places co-terminosity of partners may make it easy to delegate functions to place level, where in others the remaining statutory structures may make it problematic.
Such variation is unsurprising – and in fact necessary given the multitude of local factors involved. However, it does complicate matters as it means that their evolution is unlikely to be linear. Any attempt at being too prescriptive or taking a ‘one-size-fits-all’ approach to arrangements for systems and/or places would not be appropriate, and not in keeping with the concept of subsidiarity. However, some degree of commonality or comparability is desirable.
In Integrating Care: putting the principles in place, CIPFA suggested that taking a principles-based approach would be more appropriate. This would recognise and accept the significant diversity between systems and their places and could also be phased and adapted over time as systems/places evolve differently according to their circumstances.
Both the NHS and local government are facing enormous and growing challenges – existing pressures and recovery from the pandemic and the cost-of-living crisis sit amongst wider policy reforms, political and economic pressures. Such competing priorities can distract from and add tensions to the integration agenda.
Central government departments should lead by example and demonstrate an integrated approach to co-ordinating and clarifying policy priorities for the health and care sector overall. Otherwise, it is difficult to envisage how integration has any chance of progressing ‘further and faster’ as expected.
There is a clear disconnect between immediate pressures and the longer-term investment required to focus on prevention and population health. Good financial management depends on consideration of the entire breadth of responsibilities over a long-term horizon to ensure outcomes and value for money are achieved. Achieving the vision for integration requires long-term commitment and certainty of funding. A twin track approach is necessary, to ensure services can deal with existing and immediate pressures, as well as making long-term investments to ensure services are financially sustainable and provide value for public money.
There remain areas of government policy that are misaligned with national integration policy – for example differential VAT regimes across the NHS and local government. Developing complex workarounds drains resources and distracts from the goal of closer integration. The ideal solution would be to improve policy alignment within and across government departments. However, sharing experience and improving understanding of potential workarounds would be a welcome first step.
Within this crowded landscape a shared understanding amongst partners is essential. Openness and transparency of the priorities and pressures they are facing is essential to building relationships and trust which partnerships are built on.
The 2022 White Paper commits to develop a focused set of national outcomes alongside an approach for prioritising shared outcomes at local level. As set out in Delivering outcomes in the public sector CIPFA believes that a focus on outcomes in partnership working can highlight the dependencies between services and organisations, and so help to foster a shared vision, common purpose, and improve understanding between the partners.
Creating a link between resource allocation and outcomes provides a clearer focus across partners. Good public financial management requires making evidence-based decisions on the allocation of public funds to outcomes, and the ability to track and evaluate progress and ensure value for money is being achieved.
A national outcomes framework which brings together and clarifies the overarching aims for health and social care and provides a mechanism for evaluating progress would be a helpful way to navigate these wider policy objectives. However, care needs to be taken that it does not add a further tier of bureaucracy on top of existing ‘sector specific’ national priorities. This would require a truly integrated approach to be taken from the centre, with different government departments coming together to clarify priorities across national policy and the related outcomes to be achieved through integration.
Given the extent of variation between integrated care systems and their places, the national outcomes must be broad enough to enable all systems/places to contribute to their achievement in a manner appropriate to their local circumstances. It should allow for more detailed, tailored frameworks to be developed in each ICS, reflecting the local priorities highlighted in ICP strategies, which can then be further translated down to place level. The emphasis should be on evidence-based local priorities reflecting national, rather than national prescription stifling local need and innovation.
An outcomes-based approach to integrating health and care requires long-term political and financial commitment. At its heart must sit realistic expectations of what can reasonably be achieved within the timescale and available resources.
Good governance in the public sector encourages better informed and longer-term decision-making and the efficient use of public resource. It strengthens accountability for stewardship of those resources and results in more effective interventions and better outcomes for the population.
A number of models have been proposed for place-based governance and accountability arrangements. The expectation is that all places will have adopted a model of accountability which meets these criteria and identifies a single accountable person by Spring 2023.
Some ICSs already have well-established places and others are currently developing such partnerships. However, the intention is that all place-based partnerships will continue to evolve over time as more functions (and resources) are delegated.
Given the significant variation between places, their evolution is unlikely to proceed uniformly. This is not necessarily a function of their maturity but may be due to inherent structural factors. Thus, a ‘one size fits all’ set of criteria does not seem the most reasonable approach.
A principles-based approach, perhaps incorporating minimum expectations, would recognise the diversity of places, allowing for adaptation to local circumstances and over time as places evolve. It would then be for each locality to determine the appropriate and proportionate arrangements for their circumstances, and for others to assure themselves that these are sufficient.
A good starting point would be the CIPFA/IFAC International Framework: Good governance in the public sector. Based around seven principles, this recognises that the fundamentals of good governance remain the same for an individual organisation and the system of which it is part – such as the partnerships involved in integration.
The NHS and local government operate under vastly different funding and financial regimes. Fostering a shared understanding between partners is essential if they are to build the relationships and trust required to realise the aims of integration.
Current financial regimes and funding mechanisms do not support a whole system approach to improving population health and wellbeing with a focus on prevention. A lack of funding certainty stifles the ability to plan and invest in priorities with longer-term horizons, such as prevention and reducing health inequalities.
The 2022 White Paper sets the ambition that pooled budgets will eventually cover much of the funding for health and care services at place level and committed to simplify the arrangements for doing so and produce further guidance by Spring 2023. In practice pooling budgets and partnership arrangements can be complex and involve a lengthy negotiation process between NHS and local government partners. In the current climate of service and financial pressures, there are concerns that these, together with the complexities and misalignments of policy, may disincentivise pooling and partnership arrangements.
However, pooling budgets is only one tool in the box, and a wider view should be taken of how to mobilise resources across organisational boundaries. Delegation of functions and resources from system to place level should be underpinned by a place level financial framework, to ensure that funding flows reflect decision-making and support the delivery of shared outcomes. Again, this should be based on principles which can be adapted to suit local variation. A good starting point when considering such a joint financial framework would be the principles of good public financial management contained in CIPFA’s Financial Management Code.
Developing a combined principles-based framework for place which incorporates robust governance, accountability and finance arrangements would not only allow for the significant variation but would also be flexible to enable arrangements to adapt and become more sophisticated as places mature and evolve. Such a framework should be informed by local circumstances and aligned to the ‘national ask’.
Given that the evolution of places over time is unlikely to be linear, it will be helpful for places to identify where they are on this journey and chart a course for the progressive nature of integrated care in their locality.
 Evidence includes Institute of Health Equity, Health Inequality in England: The Marmot Review 10 Years on, 2020 and more recently CIVITAS, International Health Care Outcomes Index 2022.
 Evidence includes sources such as: World Health Organisation, Social determinants of health and Robert Wood Johnson Foundation, Healthy Communities.