The white paper focused on integration sets out general aspirations, but includes several specific areas where there is a commitment to further work. Although presented as a Department of Health and Social Care's (DHSC) document, the foreword is jointly from DHSC and the Department of Levelling Up, Housing and Communities (DLUHC). The document is presented as being part of a set of reforms that also includes the Social Care white paper, the Health and Care Bill and reforms to public health. Many of the proposals in the document rely on the passage of the Health and Care Bill through Parliament.
One of the major strands is shared outcomes which prioritise people and populations. The framework for this will be developed with stakeholders ready for implementation in 2023. It will put the focus on ‘Place’ level within the Integrated Care System (ICS), and local areas will be able to choose local health priorities “that matter most to their citizens” alongside national commitments.
With a view to ensuring strong leadership and accountability, the white paper promises criteria for place-level governance. Local areas will need to adopt a suggested model or its equivalent by April 2023. This includes the requirement for a single person – agreed by the Integrated Care Board (ICB) and appropriate local authorities - who will be accountable for shared outcomes across the local area. This role does not replace existing accountability in either local authorities or the National Health Service (NHS).
The ‘place board’ model would bring partners together to pool resources and plan jointly. The local authorities and ICB would delegate functions and budgets to the place board. The place board lead would be agreed by the ICB and the local authority (or authorities) for the place.
It is worth noting that, as part of its role in assessing ICSs, the Care Quality Commission would consider outcomes at place level as part of that assessment.
Finance and integration
In order to link finance and integration, the white paper includes a commitment to work with local authorities and the NHS to develop further guidance on financial alignment and pooling, aiming to simplify the regulations.
Digital and data
Maximising transparency and personal choice covers the need to have better records that are focused on people rather than organisations. Integrated data and technology systems are presented as enabling people to take more control over their health and care. The key actions include:
Digitising: records of health and care delivery to be digital, not paper, everywhere;
Connecting: different systems to exchange information;
Transforming: Digitally enabled transformation and the funding, skills and time needed to do it well.
This section recognises the implications for people as both services users and workforce, including the need to upskill staff.
The ICS is seen as the leader to ensure rapid digital adoption, including the expectation of an ‘ICS first’ approach so that organisations within an ICS are encouraged to use the same digital systems.
The section on health and care workforce and carers focus on workplace integration and presents the ICS as a way of overcoming barriers. Among the options suggested are:
Learning and development;
Progression and movement within and between sectors;
Place-Based Workforce Integration.
The section highlights some of the issues – for example, workforce planning taking place at different levels - but doesn’t provide a clear solution.
These include a large number of actions that range from the very specific to vague aspirations. Some of these are Government actions whereas others will be down to ICSs.
The document concludes with 17 questions about which they will “engage stakeholders across the sector”.
This white paper comes with several challenges both in the document itself and in the situation in which it is being presented. Although there are goals that would be supported, the plan seems designed for organisations rather than people who use services and their carers. Although there are case studies describing how people can benefit, the connection is not clearly made in the document as a whole.
The context provides possibly the greatest challenge. The NHS has faced two years of significant pressure and the white paper presents further work to be undertaken in short time frames. Alongside this, the NHS is undergoing major change – subject to the Health and Care Bill being passed by Parliament – with ongoing personnel changes across the country.
What does this mean for Healthwatch?
Although the white paper lacks detail, it does provide a useful framework for working with the ICS and local providers. It presents an opportunity for Healthwatch to carry out our role as a champion for patient voice and for people as service users.
More problematically, the focus on place-level – although welcome – confuses the role of the ICS and ICB. Healthwatch will need assurance about where responsibilities lie and decisions are made, so they can contribute effectively and appropriately. The emphasis on place must not compromise Healthwatch’s ability to work, with other Healthwatch where necessary, at system level ensuring that the ICS hears the full range of voices of its communities.