Integration is about more than legislation and structures, MPs told

The Commons Health and Social Care Committee is currently holding an inquiry into the Department of Health and Social Care’s white paper on legislation to support integration and the move to integrated care systems (ICSs). The white paper was published in February and the HFMA has published a summary of the proposals.)

Richard Murray (pictured), chief executive of the King’s Fund, told the committee that the proposals were a move in the right direction. But he warned that they would need to be accompanied by changes in behaviour and culture, as well as funding, both for the NHS and broader public services. ‘It is a structure that makes it easier to work in [an integrated] way, but we can’t rely on legislation alone to deliver all the gains of integration,’ he said. ‘Much of the heavy lifting is done at place level, often on local government footprints, so there is a lot outside this legislation that needs to be done as well.’

Hugh Alderwick, head of policy at The Health Foundation, agreed that the emphasis on collaboration between the NHS, local government and other partners was clearly right and largely followed the direction systems were already taking.

‘But the flipside is that the benefits of the kind of integration on offer in the white paper, which is really about structures and formal rules, risk being way overstated,’ he said. He agreed that securing collaboration in practice would depend more on ‘culture, management, sufficient resources, trust and time to develop new care models’, much more than structures and rules.

He added that there were also questions remaining about what ICSs are and what they will do. ‘On the one hand they are a big opportunity to improve some of the pretty murky accountabilities at a local level to provide more clarity about who is in charge,’ he said. ‘But, at the moment, it is not really clear how much power ICSs will have over providers, for instance. And we now look like we have two ICSs – an NHS ICS and a local government partnership ICS. What is the relationship between those two and is there a risk that the NHS dominates?’

Mr Murray insisted that ICSs must not simply be big clinical commissioning groups and an exercise in rearranging senior staff. Instead, the changes needed to lead to much closer working with providers, local government, the voluntary sector and parts of the private sector. ‘A lot of that comes at place level – at a level below ICSs. So, one of the things we have to watch here, as all the attention switches to ICSs on their very large footprints, is that we don’t lose the fact that what matters for patients and frontline staff is what goes on locally,’ he said. ‘There is a risk that as you merge CCGs, that were sometimes closer to local government colleagues, you lose that.’

ICSs would need to keep some local functions and be able to devolve budgets down to that local level to work with GPs and communities, he added.

Nigel Edwards, chief executive of The Nuffield Trust said there were a lot of outstanding questions about the proposals. One of the strengths of the white paper was its recognition that systems served diverse areas with different characteristics and different geographies. ‘But the downside of this is that it is very difficult to specify an answer about how to deal with these issues and mitigate the risks,’ he said. He added that patience would be needed while systems worked their way through the changes.

There was general agreement that the proposals represented a missed opportunity in terms of social care.

‘The white paper is pretty silent on reform of social care,’ said Mr Alderwick. ‘There are some limited policy measures, which without additional funding look a little perverse in places, but are such a long way from adding up to comprehensive reform,’

He added that this was an ‘ongoing political failure’  that the government was choosing to prolong. ‘Without adequate funding for social care and without thinking comprehensively about the workforce and other challenges facing the system, the rest of the objectives in the white paper around the NHS in terms of improving population health will be very, very difficult to meet,’ he said.

In a further session, representative bodies called for a much greater focus on long-term workforce planning. Danny Mortimer (pictured), chief executive of the NHS Confederation, suggested that some of the tasks around workforce planning could be devolved to ICSs.

‘ICSs with their ability to relate workforce needs in the longer term to the needs of their population and services can become an engine for producing the plan,’ he said, adding that ICSs were also best placed to understand how innovation might impact on workforce numbers.  And he added that the plan should not be constrained by the short-term view of the Treasury in terms of the resources that are currently available.

He rejected the suggestion that constraining the numbers of doctors and nurses was the best way of containing the long-term growth of NHS spending. ‘My direct experience is that in times of shortage, there is an additional cost for the NHS and social because of the use of premium cost labour,’ he said. Overtime the NHS should move to a position of oversupply in some of the key degree-educated job markets as this would help avoid these additional costs.