Written Evidence submitted by Professor Judith Smith, Professor Jon Glasby and Professor Robin Miller at the University of Birmingham (HSC0868)


On 11 February 2021, the Department for Health and Social Care published a White Paper Integration and Innovation: working together to improve health and social care.   The White Paper sets out proposals for legislative change in the NHS in England, with the overall aim of enabling more integrated health and social care, and a stronger focus on collaboration, rather than competition, within the NHS.  This submission to the Committee from the University of Birmingham draws on our health and social care research to highlight what we consider to be the risks and opportunities of the proposed legislative changes.  In our view, the key issues include:

-          We welcome the focus on seeking to bring about more integrated health and social care, which research consistently finds to be beneficial to patients and their carers, and accords with the NHS Long Term Plan and international trends in health and care policy.


-          Legislative change is likely to be helpful in simplifying and formalising some aspects of a very complex NHS policy and regulatory infrastructure, including a reduction in some unnecessary use of competitive tendering and related practices.


-          The arrangements proposed for the governance of local Integrated Care Systems appear very complicated, and there is a need for greater clarity as to where decisions about capital spending, revenue allocation, and service changes will be made and accounted for.


-          The focus on changes to organisations and governance as a means to achieve integrated care will likely prove very time-consuming and distracting in the short to medium term, given all that is known from research about the costs and consequences of structural reorganisation.


-          We are particularly concerned about the timing of some of the proposed changes, given the pressures facing both health and social care as they seek to recover from the pandemic, deal with significant pent-up demand for services, and all with a depleted and exhausted workforce. 


-          It is of note that once again in the NHS, it is the commissioning function that faces the more significant organisational upheaval and reorganisation, and this risks weakening further the role and influence of health planning, priority-setting and commissioning.


-          The White Paper is focused on integrated health and social care, yet is largely concerned with proposals for the NHS, and with relatively little attention to the vitally important planning and commissioning role of local government, social services and the third sector.


-          The proposals have less of an emphasis than expected on the role of primary care and general practice.  Primary care networks have played a pivotal role in local responses to the pandemic, have significant potential to develop place-based care, and yet their role within Integrated Care System governance and decision-making is currently somewhat unclear.


-          The most glaring omission from the White Paper is a clear plan for reform of the funding of social care, and likewise of measures to address the highly constrained capacity of social care provision and workforce.

Working together and supporting integration

  1. We know from research studies over many years that successful implementation of integrated care needs sustained hard work by local health and social care providers and commissioners. In particular there is a need to tackle: data-sharing across services and organisations; financial and budgetary complexity; involving frontline staff in planning new services (and not just senior managers); having really meaningful service user engagement; and supporting quality improvement and service development work on a long-term basis.


  1. Structural and organisational changes typically fail to deliver many of the service and economic benefits promised by policy makers.  Judicious use of changes to financial, governance and regulatory arrangements can however be a helpful element of moving to more integrated care but only as part of a sustained focus on new ways of organising local health and care services.


  1. Central to achieving better integration is the ability of professionals to collaborate successfully. Whilst there is now greater recognition of this within professional education programmes at undergraduate and postgraduate level, this remains limited and needs to become a significant part of continuing professional development opportunities.


  1. Effective multi-disciplinary team working is frequently cited in research as being critical to inter-professional working.  This is however difficult to implement, and to do so in a manner that can be sustained longer term.  Findings from the National Evaluation of Integrated Care and Support Pioneers, led by the London School of Hygiene and Tropical Medicine and involving the University of Birmingham, point to the importance of multidisciplinary team working organised with and around primary care. Furthermore, enhanced collaborative skills are not only needed by those professionals working on the frontline but also those in senior and professional support roles such as finance, contracting, planning and commissioning.
  2. The new ‘discharge to assess model’ proposed in the White Paper as a mechanism for ensuring more rapid discharge of patients from hospital to their home, a care home, or some form of intermediate care where they can have a thorough assessment of ongoing care and support needs, sounds positive in principle.  There is however a risk that this will be interpreted as a hospital-centric approach, which is ultimately based on a ‘throughput’ model of care, rather than a more social model that seeks to work with and support people undergoing major changes in their lives and helping them to make potentially very significant decisions about their futures. 
  3. All the available evidence suggests that any interim hospital discharge service needs to be well-funded and focused firmly on providing active rehabilitation in a way that works for the individual.  Otherwise it can simply become a ‘holding bay’ for people discharged from hospital and end up being permanent rather than temporary.  We know from research that premature and poorly organised discharge can be just as problematic as delayed discharges.
  4. It is not clear to us that the creation of organisational arrangements for Integrated Care Systems will per se make these ‘ingredients’ of integrated care more available and effective, but they do hold potential to create a more receptive context for this important, complex operational work to be undertaken to resolve budgetary, information and other matters.
  5. While the focus on improving discharge is positive, there is also a need to have more capacity to prevent admissions.  While health and social care professionals tend to only see the person as they come in the front door – and therefore focus on whether or not individual admissions are ‘appropriate’ at that moment in time – our research has shown that it is only really older people and their families who have a longitudinal sense of their particular journey through health and care services and what might have been done differently at an earlier stage.
  6. Community hospitals might provide an important and valued resource for local communities, with scope for more local, person-centred, homely approaches to care, as evidenced in research the University of Birmingham undertook recently for the National Institute for Health Research.  However, there have been many closures and service changes in community hospitals – arguably based on more narrow financial considerations in a period of austerity, rather than broader notions of what patients and communities might value.

Reducing bureaucracy

  1. We welcome the White Paper proposals to shift the focus of NHS policy from competition toward collaboration and partnership, which goes with the grain of health and social care practitioners’ and decision-makers’ desire to enable better integrated care for people living with complex conditions, and to have a health and care system that is more effective for patients and less bureaucratic for those charged with running it.   


  1. Whilst some contestability of health services is important to ensure that commissioners secure value for money, and can shape new models of care to meet local needs, it is refreshing to learn that in future there will be a more nuanced and proportionate approach to the use of competitive tendering.  There has been significant frustration in recent years about the cost (financial and in management time) of tendering for core NHS services where there is in reality only a single viable provider, and where the process of tendering can damage local collaboration across services, and entail an overly transactional approach, where goodwill and flexibility risk being squeezed out


  1. The use of commissioning and associated transactional mechanisms to bring about integrated care can lead to excessive costs in service specification, and lose the commitment and engagement of frontline staff, as evidenced in research.   That said, there is also a need to ensure that health and social care does not become a ‘closed shop’ with insufficient opportunities for the voluntary, independent and community sector to be directly involved in the delivery of health care services.


  1. The proposal to remove the role of the Competition and Markets Authority from assessing mergers within the NHS is to be welcomed, for experience has shown that this has led to unnecessary bureaucracy, legal costs and delays, whilst impeding necessary local service change which is more effectively managed by statutory accountable bodies within the NHS and local government, with the close involvement of health professionals, politicians, and local communities. 


  1. There will however be a need for clear guidance for Integrated Care Systems about their role and remit in relation to service change and organisational mergers, in the context of expanded powers for the Secretary of State, to ensure a proper balance of local and national consultation and involvement, and the ability to make and enact necessary (and sometimes unpopular) decisions.  Furthermore it must be remembered that social care will continue as a competitive market which needs to be shaped responsibly. It is therefore important that these development are not explained as a wholescale move from market mechanisms.

Organising around ‘place’

  1. We welcome the focus on ‘place’ as the organising principle for local health and care services, in a context of seeking improve population health, and we have previously explored this though the lens of needing an ‘NHS Local’ body to plan, oversee and account for health and care servicesThe arrangements proposed for the governance of local Integrated Care Systems appear however to be very complicated, and there is a need for greater clarity as to where decisions about capital spending, revenue allocation, and service changes will be made and accounted for.  There is particular potential confusion between the role of sovereign NHS foundation trusts and the overall Integrated Care System NHS body in relation to these matters. 


  1. The proposal to have an Integrated Care System Partnership to oversee the local Integrated Care System local NHS body, with the latter comprising representatives from the full range of NHS Trusts and Foundation Trusts and primary care, whilst the former draws in local government, social services and the third sector, seems complex and potentially confusing and costly.


  1. It is also unhelpful to delineate between clinical health care organisations and wider integration around social determinants as there is a considerable danger that NHS organisations will see their body as the most important with the wider partnership having a more consultative and symbolic function rather than being a main point of accountability.  


  1. There is a need for further clarification of the role of Primary Care Networks and general practice within Integrated Care Systems.  With the merging of Clinical Commissioning Groups into new Integrated Care Systems, there is a risk of reducing primary care influence within local planning and commissioning.  Primary Care Networks are relatively new organisations within the local NHS, and provide an important mechanism for planning, organising and extending local health and care services. We have examined their potential future role in research for the National Institute for Health Research and in an article with the Health Foundation.

The risks of reorganisation

  1. The focus on changes to organisations and governance as a means to achieve integrated care will likely prove very time-consuming and distracting in the short to medium term, given all that is known from research about the costs and consequences of structural reorganisation.  The perils of NHS structural change explored by HSMC colleagues in 2001 as ‘redisorganisation’ continue to hold true, and there is a real risk of managers being very distracted by the personal and organisational anxiety of dismantling an organisation and shifting functions into new Integrated Care Systems.  It is of note that it is once again the commissioning function of the NHS in England that is likely to be most destabilised by organisational change.
  2. The context of the COVID-19 pandemic, and its potential further waves along with the major challenge of recovery of NHS services make the risks of changes to structures and governance all the more significant.  We suggest that careful planning of the implementation of Integrated Care System proposals be undertaken, with a timescale that has some flexibility to enable managers and leaders to focus on post-pandemic recovery, support an exhausted and depleted health and social care workforce, and develop local arrangements in a manner that is appropriate to the specific context, which may mean some areas being ahead of others.

Enhancing public confidence and accountability

  1. The White Paper proposals say relatively little about the patient and public voice within the planning, commissioning and funding of integrated health and care services at a local or regional level.  The process and extent of involvement of people with lived experience and community representation within Integrated Care Systems need to be clarified. For example, work is needed to determine the respective roles of NHS foundation trust governors, patient participation groups in primary care, and Healthwatch. 
  2. Government policy has long sought to boost inter-agency working, public and user involvement and strategic commissioning, but significant weaknesses remain in all three agendas.  We argued in a paper entitled ‘Creating NHS Local’ that the NHS, when faced with very difficult strategic issues, is often good at making the ‘right decision’ (very rationale, data-driven, technical expertise, research and development), but that local government is often better at making decisions in the ‘right way’ (in a way that pays attention to the politics of service change [with a small p]).  This is as much about issues of identity and legitimacy than it is about technical issues or making rational decisions
  3. We suggest therefore that these White Paper proposals would benefit from greater engagement with local government, and it may be worth considering scope for local government-led commissioning of some aspects of integrated health and social care, as we argued in our ‘NHS Local’ analysis.  Learning could also be gained from the recent experience of devolved health and care commissioning in Greater Manchester.  

Delivery of long-term plans for social care

  1. The most pressing issue in relation to the health and social care system is the lack of funding and workforce capacity in the social care sector and the considerable impact this has on the wellbeing of individuals and their families, and the effective delivery of primary and secondary health care services.


  1. The biggest omission in the White Paper is the lack of a vision for the future reform and funding of adult social care.  While there have been multiple pledges to produce a long-term plan, these have not yet materialised, there have been at least 12 government Green/White Papers, vision documents and independent reviews since 1999, and we are no closer to reforming the funding of adult social care than twenty years ago. Indeed, of proposals relating specifically to funding, none of the main recommendations have been implemented, and it is difficult to believe it will be 13th time lucky.


  1. Our work on the future reform and costs of adult social care identifies a ‘lost decade’ in which previous reforms stalled or went backwards, leading to rising levels of unmet/under-met need and rising levels of ‘self-funding’; concerns about care quality; and negative impacts on carers, care staff, care providers and partner agencies.  Repeating a warning first given in the run up to the 2010 White Paper, doing nothing is not an option – and the adult social care system may already have reached breaking point. 
  2. As our analysis suggests: “Many of the impacts summarised above involve people and their families suffering quietly in their own homes – the sheer human misery caused by our ‘lost decade’ is simply not as visible as financial pressures on more prominent, popular and better understood services (hospitals or schools, for example). When social care for older people is cut to the bone, lives are blighted, distress and pressure increase, and the resilience of individuals and their families is ground down. Yet this happens slowly – day by day, week by week and month by month. It is not sudden, dramatic or hi-tech in the way a crisis in an Accident and Emergency department may be, and tends to attract less media, political and popular attention.”


  1. Concrete and timetabled plans need to be confirmed urgently for reform of social care funding. This must incorporate more than the financial costs of older people regarding long term care (although this is important) but also agreement about the wider contribution of social care to addressing health inequalities and how this should be funded.


  1. Social care has arguably greater experience of engaging community resources in providing more person-centred and preventative models of care. Ensuring that social care is properly resourced will enable this sector to contribute more thoroughly to developments in local Integrated Care Systems, for example for the development of community-based solutions and strengthening of related assets. The wider local authority, most notably public health, will be able to make a substantial contribution to this area of work, and this will need careful planning and resourcing within wider Integrated Care Systems, along with assurance of local government having a clearly articulated and influential role at each level of place-based commissioning and planning.


Professor Judith Smith

Professor Jon Glasby

Professor Robin Miller


March 2021