The UK government has published a policy white paper setting out its proposals for reforming the NHS. The paper, Integration and innovation: working together to improve health and social care for all (HTML version) - GOV.UK (www.gov.uk) sets out legislative proposals for a Health and Care Bill. It builds on previous guidance going back to the 2014 NHS England » NHS Five Year Forward View and more recently the 2019 NHS Long Term Plan.
‘Working together to integrate care’
The headline grabbing focus of the paper is more and better integration of care between primary care, hospitals, community and mental health services, and care homes. The paper focuses on two forms of integration: (1) integration within the NHS to remove some of the boundaries to collaboration and to make working together an organising principle; and (2) greater collaboration between the NHS and local government, as well as wider delivery partners, to deliver improved health outcomes and wellbeing for local people. To achieve these goals, the paper proposes to establish statutory integrated care systems (ICSs) comprising:
- Statutory ICS NHS Body – responsible for day-to-day running of the ICS, including developing a plan to meet the health needs of their population, developing a capital plan for NHS provision and securing the provision of health services to meet population needs. It will have a duty to meet the system financial objectives allocated to it by NHS England.
- Statutory ICS Health and Care Partnership – a body bringing together NHS, local government and partners that will be responsible for supporting integration and developing a plan to address the systems’ health, public health and social care needs.
The proposals for ICSs provide for a core set of requirements for each system that the partners can then supplement with local arrangements. There is a recognition of the need to avoid a one-size-fits-all approach and enable flexibility for local areas to determine the best system arrangements for them. Systems will be helped in this regard by proposals to allow various NHS bodies to form joint committees to which functions may be delegated, with the power to make decisions on behalf of the organisations within the ICS.
The detail and direction of travel from the white paper raise a number of significant issues, including:
- Commissioning – The paper’s proposals will involve a radical rethink of NHS commissioning.
- Place-based arrangements – Place-based arrangements between local authorities, the NHS and between providers of health and care services will be at the core of integration. Legislation will not prescribe how these arrangements are put in place or what they need to involve – that will be left to local organisations to arrange.
- Collaboration between trusts – As described above, the paper emphasises the importance of collaboration between organisations to improve care, though it does not propose changes to the governance structures, statutory financial duties or CQC arrangements for trusts. The role of providers in these systems will need careful consideration and will need to be informed by the earlier guidance, issued by NHS England and Improvement, Integrating care: Next steps to building strong and effective integrated care systems across England (November 2020), which makes recommendations regarding the role of ‘provider collaboratives’. We have produced a detailed report together with partners about how to build effective ‘horizontal’ provider collaboratives across an ICS – please contact Jamie Foster for a copy.
- Service reconfiguration – The paper proposes a speedier process for service reconfigurations.
These initiatives will be supported by a broad duty to collaborate across the health and care system and a triple aim duty on health bodies, including ICSs, to pursue better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.
The white paper focuses on ‘reducing bureaucracy’, which builds on the Department of Health and Social Care’s paper Busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in the health and care system in England - GOV.UK (www.gov.uk). This will involve the removal of the role of the Competition and Markets Authority and existing public procurement rules relating to clinical services. Instead, the NHS will be subject to a bespoke ‘Provider Selection Regime’ that will give commissioners greater flexibility in how they arrange services than at present. The NHS has committed to consulting on the new regime: NHS England » NHS Provider Selection Regime: Consultation on proposals. The Consultation proposes that where procurement processes can add value they will continue, but that will be a decision that the NHS will be able to make for itself. These changes retain a division of responsibility between strategic planning and funding decisions on the one hand, and care delivery on the other, but allow for its operation in a more joined-up way.
- Workforce – The paper contains little detail about workforce, but it does propose the introduction of a duty on the secretary of state duty to publish a report every parliament, which will support greater clarity around workforce planning responsibilities. In addition, the proposals regarding joint appointments will support integration between organisations. There is, in addition, the shift of workforce from CCGs and some areas in NHS England to the new systems (including the ICS).
- Digital and data – The paper commits to improving the quality and availability of data across the health and social care sectors, which is critical to effective integration and will enable the digital transformation of care pathways. There is, however, no further detail about adoption of digital and other technology, which, we assume, will become the responsibility of ICSs to arrange.
- Infrastructure – The paper does not make any specific proposals regarding NHS estate, with previously published guidance Health Infrastructure Plan continuing to set the framework for infrastructure upgrades across the NHS.
- Safety and quality – a new statutory Health Services Safety Investigations Body will be established, alongside a statutory medical examiner system within the NHS for the purpose of scrutinising all deaths that do not involve a coroner and increase transparency for the bereaved.
- Social care – An enhanced assurance framework will be introduced to improve the outcomes and experience of people and their families in accessing high-quality care and support. In addition, the secretary of state will be given the power to make emergency payments directly to social care providers. The role of the Better Care Fund has been enhanced by being separated from the NHS mandate setting process. However, the wider challenges faced by the social care system will be addressed by separate proposals for reform, to which the government states that it remains committed.
- MHRA – The paper proposes to allow the Medicines and Healthcare products Regulatory Agency (MHRA) to develop and maintain publicly funded and operated medicine registries to provide patients and their prescribers, as well as regulators and the NHS, with the information they need to make evidence-based decisions.
- Education and training - Local Education Training Boards (LETBs) will be removed from statute to give Health Education England (HEE) more flexibility to adapt its regional operating model over time.