Reform analysis: Integration White Paper
Completing a trio of health announcements within the space of a week, today the Government published its integration White Paper.
A bit of background to this one: for decades, governments and NHS leaders have seen ‘integration’ as a panacea for the range of problems our health and care systems face, from more effectively managing long-term health conditions to reducing emergency admissions, driving down costs to driving up patient satisfaction. All great — and necessary — aims for a system under immense pressure and struggling to improve patient outcomes.
The rather awkward elephant in the room is that there is scant evidence integration, at least in the forms it has been tried, actually delivers those aims. In 2017, for example, the National Audit Office argued that in all that time, none of those outcomes had been achieved.
Yet the move towards Integrated Care Systems has carried on apace. And so too have the warnings about its efficacy. An in-depth evaluation by the Nuffield Trust late last year concluded that there is limited evidence that integration policies in any of the UK’s four nations “had made a difference to patients, or to how well services are integrated”. A Centre for Policy Studies paper looking at integration in Manchester — the most advanced case of integration in England — found that the key metrics set out by the city were actually deteriorating.
Which rather begs the question: why are the Government pushing full steam ahead with a model for which there is, at best, only very small scale evidence to support?
At the same time, it may help explain why the Paper is in fact a green paper in all but name. Rather than detailing how it will address the many and varied challenges, the Department for Health and Social Care instead lists a load of (pretty fundamental) questions that it will “engage with stakeholders and partners” to answer. These cover everything from how to overcome the lack of shared goals, align misaligned financial incentives between organisations, what the balance of accountability should be between central and local institutions, and how to ensure the health and social care workforces can work seamlessly together.
It’s not that the White Paper is completely void of any good ideas — there are promising proposals on skills and digital, for example — but on the big questions, the strategy laid out today comes up well short of the delivery details needed to underpin the Health and Care Bill going through Parliament.
Integrated leadership & defining accountability
Drawing lines of accountability for planning and delivering health and care services has always been a complex exercise. A tendency to introduce new acronyms with new powers into an already fragmented system leaves even health experts asking questions about where responsibility lies for funding, commissioning and providing health and care services. This White Paper does little to allay concerns here.
In a section entitled, “Clear Accountability” we are presented with the below diagram. Not quite our definition of clear.
The major thrust of the White Paper concerns what should happen beneath the Integrated Care System (ICS) level — at the level of “place” in NHS-speak. The logic here is sound — making care more personalised and responsive to the needs of citizens means organising it at a much smaller scale than an ICS (population: 1-3 million). Here’s what we can glean so far in terms of how it will work: Integrated Care Boards (ICB) — the group of providers which oversee ICS commissioning — and councils will delegate their functions and budgets to a new “place board”. This place-board will be overseen by a “single person accountable for the delivery of shared outcomes and plans”, who will be chosen by the ICB and the local authority.
But if responsibility is devolved down to a single accountable person at place level, what exactly is the point of the ICBs within the ICS? Right now it looks like adding another confusing layer of bureaucracy and administration into an already overcrowded system. (Quick question: does it feel to anyone else like “place boards” could be a new name for CCGs?)
On the core issue of accountability, we are left not with a statement of intent but with a series of open questions about how to achieve it in this new ICS world. And when it comes to governance and decision-making, the Paper makes no headway in resolving the practical challenge that we, and others, have frequently raised: how do you avoid ICSs being acute system-dominated and ensure local authorities are genuinely equal partners? Oh, and how are citizens actually going to have a say in what their local health and care services look like? The Paper raises more questions than it provides answers.
Again, this is an area where laudable ambition (“Wherever possible, pooled or aligned budgets should be routine... eventually covering much of funding for health and social care services at place level”) lacks a robust action plan. The Better Care Fund is hailed as evidence of the success of pooled health and social care budgets, and the Paper references the fact that places have put in more than the mandatory minimum. However it doesn't reference the fact that this pooled fund represents a tiny fraction of the money going into health and social care. The Paper also points out that while there is currently significant scope for pooling budgets, “it largely relies on local leadership to drive this” – which is all well and good where you have leaders minded to take this approach, but the fact pooled budgets are the exception not the rule shows this is insufficient. Hence the need for action.
Yet the only actual commitment in the Paper is that the Government will undertake a review of current legislation covering pooled budgets (section 75a of the 2006 Act) and then publish revised guidance, but “this will continue to be subject to both NHS and local authority partners agreeing locally what constitutes fair”. In fact, while stating that they expect funding to be pooled, the Paper explicitly rules out mandation, relying instead on local areas to act voluntarily. Hmmm. Another case of: ‘if only wishing made it so’.
Integrating and upskilling the workforce
As this White Paper rightly notes, the mark of integration’s success will be in how it delivers for patients. And that means building a workforce with a different set of skills than has tended to exist in the past. There are some real signs of intent here: giving ICSs and local places a greater say on workforce planning, developing new roles for link workers and care coordinators, and creating portable Care Certificates to make it easier for social care workers to move jobs are all positive developments.
It’s particularly promising to see the Government exploring introducing an Integrated Skills Passport to enable health and care workers to transfer their skills between the NHS, public health and social care. That’s something that we at Reform have long called for and brings a much needed degree of flexibility to a (very!) rigid labour market. Given that a cultural divide — and frankly, a degree of condescension on the part of the NHS — exists between the health and care systems, increasing opportunities for joint training and learning experiences is vital.
While joint training and working are important enablers of integration, chronic staff shortages yet again present the biggest challenge. Big gaps in the health and care workforce remain unaddressed and without a clear plan for progress all aspects of the Government’s health agenda, from integration to clearing the backlog, will be an uphill battle.
Integrating data & making the most of digital
This is the most promising and worked-up area of the White Paper — and the only thematic chapter that doesn’t end in a list of questions for stakeholders. The Government is right to say joined-up data will be “central” to delivering on the key priorities of ICSs, including smoothing treatment pathways, improving population health management and understanding what works. Its big ambition is for everyone to have access to a “shared care record” by 2024 that can be accessed by citizens, caregivers and care teams. Huge progress has already been made on this in health, particularly, as the White Paper points out, due to a “rapid adoption” of digital records during the pandemic.
However, the achilles heel of this vision is integrating health records with social care records. This is because it relies on having technology that can enable data sharing. The £150 million of new funding for digital transformation, announced in December’s adult social care White Paper, will help. But by this Paper’s own admission, only 40 per cent of social care providers have fully digitised records. The current rate of increase in adoption — 3 percentage points a year — offers little reassurance. To reach 100 per cent by 2024 that rate would have to increase tenfold. And sadly this Paper contains no plan for how that will be achieved, stating merely that ICSs should “work with partners to drive adoption”.
More promising was the White Paper’s commitment to using data in ICSs to proactively improve population health. This will be done by analysing information on people’s living circumstances and individual risk factors, to develop “personalised and predictive care”. This is a great ambition, which recognises the major impact that factors outside the health and care system can have on health outcomes. As ever, the success of this approach will rely on having staff and infrastructure to take advantage of data-sharing. And while the Paper says that it will formally recognise the “Digital Data and Technology” profession within the NHS, there is little on closing the digital skills gap in health and social care.