Integration and innovation – NHS White Paper Health and Social Care Bill

The NHS White Paper Integration and Innovation: working together to improve health and social care for all’ was published on 11^th February 2021.  It builds on the policies set out in the NHS Long Term Plan and ‘Integrating Care: next steps to building strong and effective integrated care systems’ published by NHS England and Improvement on 26^th November 2020.  The White Paper forms the basis for a Health and Care Bill that will go through Parliament later this year with the intention of becoming law by April 2022.  The Government has explained that it is not intended as a comprehensive package of reforms and should be seen alongside broader reforms to Social Care (as yet still awaited), Public Health and Mental Health.

The NHS White Paper aims to remove some of the barriers to integration within the NHS, and between the NHS and Local Government and wider partners, through setting out a range of specific changes to accelerate improvements that need primary legislation.  It proposes putting Integrated Care Systems (ICSs) on a legislative footing to take on the healthcare commissioning functions of Clinical Commissioning Groups in England from April 2022.  An ICS NHS Body will be created with a unitary board, and this will be directly accountable for NHS spend and performance, and securing the provision of health services to meet patients' needs.

The proposals in the White Paper recognise the need for two forms of integration: integration within the NHS to remove cumbersome barriers to collaboration and to make working together across the NHS an organising principle and moving away from competition; and integration between the NHS and others, principally local authorities, to deliver improved outcomes to health and wellbeing for local people.  In line with the latter a wider ICS Health and Care Partnership will have responsibility for developing a plan that addresses the broader health, public health, and social care needs of the system. 

Legislation and arrangements relating to ICSs are intended to complement and build on existing place-based structures for integration between the NHS and social care, such as Health and Wellbeing Boards, Health Overview and Scrutiny Committees, the Better Care Fund and existing powers to create pooled budgets.  It recognises the need for a population focussed approach based on what matters to local people, acknowledging the role of Healthwatch and other organisations in combining commentary on services with supporting co-production of plans at both place and ICS level. 

The White Paper also proposes changes to NHS-related competition rules, new powers of intervention for the Secretary of State, a new duty for CQC to assess local authorities’ delivery of their Adult Social Care services, a new legal framework for discharge to assess to replace the legal requirement for all assessments to take place prior to discharge, and requirements to share data, as outlined below:

• A duty to collaborate will be placed on NHS organisations (both ICSs and providers) and local authorities.  There will be specific Guidance as to what delivery of this duty means in practice in recognition of the fact that collaboration may look very different across different kinds of services.

· Proposals also allow for ministerial intervention in service reconfigurations at any point of the reconfiguration process, as well as removing the current local authority referral process to avoid creating any conflicts of interest, statutory guidance on how the process will work is to follow.

· A new duty for the CQC to assess local authorities’ delivery of their adult social care duties, with the aim of reducing variation in the quality of care.

· Formally embedding in legislation the ‘Discharge to Assess’ approach to discharging people from hospital.  This builds on the good practice approach to discharge developed in East Sussex through ‘Home First’, and the principle of assessing people’s onward care needs in their own home or in residential and nursing care environments focussed on supporting independence.  This approach was further embedded during the COVID-19 pandemic, to support the requirements set out in the Hospital Discharge Service: Policy & Operating Model, published in 2020 in response to the pandemic.

• The Department of Health and Social Care (DHSC) has recognised the value of social care data during the pandemic, and in particular the challenges faced in accessing comprehensive and accurate data from independent sector providers. The White Paper proposals set out plans for data to be collected through provider systems and existing data sets.  Further clarify will be required to understand how this will work in practice and to what extent this will be able to ‘reduce reporting burdens’.

In summary in relation to the way we work together to support integration the White Paper includes the following specific legislative proposals to establish ICSs in law:

· The creation of a statutory ICS in each ICS area, which will be made up of an ICS NHS Body and a separate ICS Health and Care Partnership, bringing together the NHS, Local Government and other partners.

· The ICS NHS body will be responsible for healthcare services and the day to day operation of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the systems' health, public health, and social care needs.

· CCGs will become part of ICSs’ and the ICS NHS Body in each area will take on the commissioning functions of the CCGs and some of those of NHS England within its boundaries.

· These organisations will merge some of the functions currently being fulfilled by non-statutory STPs/ICSs with the functions of a CCG, and bring the allocative functions of CCGs into the ICS NHS Body.

· Each ICS NHS Body will have responsibility for developing a plan to meet the health needs of the population within their defined geography, developing a capital plan for NHS providers in the area, and securing the provision of health services to meet patients' needs.

· The ICS Health and Care Partnership will have responsibility for developing a plan that addresses the wider health, public health, and social care needs of the system.  The ICS NHS Body and local authorities will need to have regard to that plan when making decisions.

· An expectation that ICSs will have to work closely with local Health and Wellbeing Boards (HWB) and the ICS NHS Body will be required to have regard to the Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies that are being produced at HWB level (and vice-versa). 

· ICSs will be encouraged to think about how they can align their allocation functions with place, for example through joint committees, and these arrangements will be locally determined.

· NHS Trusts and Foundation Trusts (FTs) will remain separate statutory bodies with their functions and duties broadly as they are in the current legislation.

· There is also provision to create a mechanism for the creation of joint committees, both between ICSs and NHS providers, and between NHS providers so that decisions can be made jointly.  The intention is that Primary Care Networks, GP practices, community health providers, local authorities and the voluntary sector could be represented within both.

· A shared duty for all NHS organisations that plan services across a system (ICSs) and nationally (NHSE), and NHS providers of care (NHS Trusts and FTs) to have regard to the ‘triple aim’ of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.

· The need for a population focussed approach to be based on what matters to local people, acknowledging the role of Healthwatch and other organisations in combining commentary on services with supporting co-production of plans at both place and ICS level.