- Our care model must change so that people experience it as a seamless package of care and support to address their specific needs and aspirations, helping them to live independent and fulfilling lives.
- Integration is not an end in itself but a means of improving health and wellbeing outcomes for individuals and communities, improving the planning and delivery of services and making the best possible use of resources
- The Better Care Fund has been a driver for joined up planning but it should be locally-led by health and wellbeing boards
- Local government provides vital local leadership and democratic accountability. This must be harnessed, particularly through strengthened health and wellbeing boards, to address the democratic deficit in the NHS
- Council and health leaders are also best placed to drive improvement at the local level. The LGA, working with national partners, is committed to supporting local areas to improve and spread good practice.
- Extracting maximum value from the new NHS funding requires priorities to be set at the local level, with minimum top-down influence from government and the NHS nationally
“Local government and NHS organisations must keep building the trust and relationships that allow joined-up planning, commissioning and oversight of health and care services. We must not allow a sense of competition to create a stand-off between health and social care or undermine the outcomes we are trying to achieve for people”
Sir David Behan CBE, Chief Executive, Care Quality Commission
LGA think piece series, 2018
Adult social care and health working together
‘Integration’ is not an end in itself but a means of achieving the triple aims of: improving health and wellbeing outcomes for individuals and communities; improving the planning and delivery of services; and making the best possible use of health and council resources. Neither is integration a panacea for the financial challenges of the health service and local government. Joining up care and support and intervening and offering early support to keep people well is a more efficient use of resources but efficiency alone is not enough to ensure the long-term sustainability of the health and care system.
The primary role of central government and national bodies in integration is to support and enable local leaders by removing the financial, cultural and structural barriers which prevent them acting for the good of their population, rather than the good of their own organisations. However, there has been increasing pressure from central government and the NHS at national level to direct integration and narrow its focus to reducing pressure on acute hospitals. In particular, the Better Care Fund (BCF) originally intended as a spur to local leaders to create their own shared plans for joined up community based services, has been used as a tool of performance management.
The introduction of a new requirement in October 2017 for local BCF plans to comply with national targets for delayed transfers of care, or risk national direction or a review of their allocations, was a step too far in central influence. Developments such as these have, in many areas, undermined local partnerships rather than supported them.
The LGA continues to support the original intentions of the BCF. Local leaders should have freedom to develop their own plans to promote integrated services, with national government playing a supportive and enabling role. But a number of factors, including financial challenges facing health and social care and the increase in national direction of local BCF plans, are identified as major barriers to greater joined up working. A recent LGA survey of council leaders and cabinet members for adult social care asked them to select the single biggest barrier to integration out of a list of ten possible choices. The top four barriers were identified as:
- Financial challenges (33 per cent)
- National direction and pressure to meet national targets (15 per cent)
- Workforce challenges (11 per cent)
- Lack of agreement between health and care leadership (10 per cent)
The Better Care Fund was announced by the Government in the June 2013 Spending Round. It creates a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their wellbeing as the focus of health and care services, and shifting resources into social care and community services for the benefit of the people. For further information, visit www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/integration-and-better-care-fund/better-care-fund.
While local leaders can do their best to use the resources they have to support local joined-up working, there is a clear demand for national government to provide sufficient funding to support integration and give local leaders the space to develop and deliver their own plans.
If this cannot be achieved, the BCF should be reformed with resources going directly to councils and deployed according to locally agreed plans overseen and assured by health and wellbeing boards.
Joining up support around the person
The primary purpose of integration is to provide better and more effective care and support to people, enabling them to live more fulfilling and independent lives. Professionals across health and care working together to join up or coordinate services undoubtedly improves people’s experience of services. But on its own it is not sufficient to deliver personalised care. To make real progress on this ambition, we need to put the person at the centre of our planning and for professionals to work with them to identify what they most value in their lives and how we can enable them to achieve it.
Personalisation is not a new concept in social care. For well over a decade, adult social care has worked with people who use services to design and recommission services to ensure that they have more choice and control. Through the Think Local Act Personal (TLAP) partnership initiative, local government and partners have committed to transforming health and social care through personalisation and community-based support.
The ‘Making it Real’ (MiR), framework developed by TLAP in partnership with people who use services and carers, describes the outcomes that genuinely personalised care and support should achieve in delivering more choice and control.
The MiR approach uses first person ‘I’ statements or ‘progress markers’ to express what service users and carers would expect to find, if personalisation is working and supporting them to be active, healthy citizens. A review by TLAP of the MiR approach demonstrated that those councils who have signed up and completed their MiR action plans:
- have a greater increase in the numbers of people who use direct payments
- have higher satisfaction levels of people who feel they have control over their life
- have provided more support to carers.
Local government has shown that personalised care at scale is possible. For example, over 500,000 people have a personal budget of whom 154,000 people have a direct payment or part direct payment in order to purchase the support they need.
Though it originated in adult social care, personalisation is now a central principle of health care as demonstrated by The Five Year Forward View which recognised that many people have the knowledge, skills and confidence to manage their mental and physical health and wellbeing and want to make choices and have control of the care and support they receive. The LGA has worked with NHS England to develop the Integrated Personal Commissioning programme to spread joined-up and personalised care across health and social care, focusing on shared decision making; personalised care and support planning; enabling choice, including legal rights to choice; social prescribing and community-based support; supported self-management and greater access to personal health budgets and integrated personal budgets.
We support the commitment to ensuring that whole-person integrated care is a founding pillar of a future care and support system. A sustainable approach to health and social care must have personalisation at its heart. Not just because this is what people want, but also because it has the power to transform the way professionals work with people and the way the system works, and this can help to transform lives.
All of this will necessitate identifying the new roles and skills which will be needed in the system and funding for sustainable skills development. For instance it may be worth exploring ways in which the new apprenticeship levy can be used more flexibly to help here but other funding will be needed given the anticipated demand for carers.
Local government, local leadership
Local government leadership is highly effective in driving forward an inclusive, place-based approach to improving health and care services and outcomes. Though only two integrated care systems are led by local council senior officers, they have demonstrated how local government can firmly embed plans to transform health and wellbeing into the wider local landscape. Local government is able to use its direct connections with communities through its democratic mandate to have honest and inclusive conversations about the rights and responsibilities of citizens with regard to their health and wellbeing. And it can also link community-based health and wellbeing services to existing community-based services, which are easily accessible to and trusted by people.
A good example of this is the Nottingham and Nottinghamshire Integrated Care System, which is led by David Pearson, Director of Adult Social Care, Health and Public Protection at Nottinghamshire County Council. It has worked closely and inclusively with its communities, workforce and partners to develop a plan that is very much grounded in the promotion of health and wellbeing, prevention, independence and self-care, through supporting community resilience and capacity building. It also recognises the vital need to strengthen primary, community, social care and carer services and the role of housing in supporting wellbeing. The fact that Nottinghamshire was selected as one of the first 10 integrated care systems is evidence that local government leadership is effective in developing a strongly inclusive place-based approach.
Accountability in the NHS
Public polling shows that people trust local councillors more than national politicians to make the right decision for their area. However, the NHS is accountable upwards to the Government, through NHS England, rather than outwards to its communities, through local councillors. The 2012 Health and Social Care Act went some way to addressing the democratic deficit in the NHS by creating health and wellbeing boards (HWBs). The boards are an equal partnership of political, clinical, professional and community leaders, with powers and duties to develop their own place-based strategy for improving the health and wellbeing outcomes of the population. HWBs are variable in their impact and influence. The front runners have undoubtedly driven local plans to develop a new approach to health and wellbeing, which invests in promoting wellbeing, early help and support delivered through joined-up community-based services and advice and information to help people manage their own health. However, not all HWBs have been effective in leading the transformation of health and care services. The LGA continues to support HWBs to ensure that they have an impact on the health and wellbeing of their communities and lead the transformation agenda.
Yet the democratic deficit in the NHS continues, in part due to the disconnect between HWBs and Sustainability and Transformation Partnerships (STPs), set up in 2015 to deliver the NHS Five Year Forward View. Though the LGA supports the intentions of STPs, the way in which they have been implemented in many areas has largely excluded existing democratic processes and has failed to engage councillors or communities in developing plans to transform services. In a recent LGA survey, council leaders and cabinet members for health and social care were asked about the extent to which they were making progress with various partners on integration in their local area. The responses are summarised below:
To what extent are you making good or moderate progress on integration with your partners?
- Council – 87 per cent
- Health and wellbeing board – 84 per cent
- Clinical commissioning group – 81 per cent
- NHS providers – 72 per cent
- Integrated care system – 54 per cent
- Sustainability and transformation partnership – 48 per cent
- NHS England – 26 per cent
It is clear that council leaders and lead members feel strongly that local councillors working with their health commissioning and provider partners are best placed to lead integration, with only 48 per cent reporting good or moderate progress in working with STPs. This is a serious cause for concern as STPs have been given the leadership of place-based integration within the NHS. Unless HWBs are given additional powers they will continue to be bypassed by STPs and people will remain unclear about how decisions are taken within the NHS at the local level. Strengthening the role of HWBs could take various forms:
- STPs could be required to engage with HWBs in the development of STP plans
- HWBs could be given a statutory duty and powers to lead the integration agenda at the local level
- HWBs could assume responsibility for commissioning primary and community care
New NHS funding – how it can benefit the system
Historically as a nation we have spent far more on the NHS than on adult social care, as the following chart shows.
Bringing about the shift from treating conditions to maximising wellbeing requires rethinking how additional resources are used to best effect. The NHS has been promised significant additional new funding, rising to £20.5 billion by 2023/24, an average of 3.4 per cent growth over the next five years. The linked NHS ten year plan is an opportunity to set out how our health service will develop over the next decade as part of efforts to ensure a world-class NHS. That aspiration can only be achieved if the NHS plan, and the new NHS funding, is used to best effect. But that assumes that the new NHS funding is sufficient and many commentators have already questioned this. For example, the Institute of Fiscal Studies and Health Foundation suggest that “spending on healthcare will have to rise by an average 3.3 per cent a year over the next 15 years just to maintain NHS provision at current levels, and by at least 4 per cent a year if services are to be improved”.
Similarly, NHS Providers have warned that “filling the gaps that have opened up in the health service after almost a decade of austerity will account for much if not most of the new money”. If such commentators are right, we run the risk of yet again using scarce new resources to manage demand pressures on our hospitals. This would be a missed opportunity to bring about more fundamental change and ensure maximum value is extracted from the £20 billion. Maximum value of the new funding should be defined at the local level, with minimal top-down initiatives from government and NHS England and maximum input from communities, workforce, service users and patients.
With sufficient local flexibility, the funding could be used to:
- Invest in prevention, primary care and community health services, with multiagency teams working closely alongside the voluntary sector to put in place early help and support
- Reinvigorate investment in intermediate care
- Reverse the cuts to district nursing, particularly so that district nurses can support care homes and extra care facilities
- Fund GP support in nursing homes and care homes to keep people out of hospital
- Fund care navigators in GP surgeries
- Invest in joined-up infrastructure, such as joint commissioning, joint assessment and shared information to track people through the health and care system and joint workforce planning
- Invest in skills development with councils taking more responsibility
- Take personalisation further with a single assessment and care planning process, which is centred on the individual and what matters to them
- Ensure that what digital activity gets delivered through the NHS Plan recognises – and funds – the critical interface with councils and the care sector, with support being given to the sharing of information through local shared records
 The Better Care Fund was announced by the Government in the June 2013 Spending Round. It creates a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their wellbeing as the focus of health and care services, and shifting resources into social care and community services for the benefit of the people. For further information, visit: https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/integration-and-better-care-fund/better-care-fund
 NHS Digital (2016), Adult social care activity and finance report, England 2016-17 – table T27 Available online: https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/adult-social-care-activity-and-finance-report-england-2016-17 (accessed 7 June 2018)
 NHS England (2014), Five Year Forward View. Available online: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 3 June 2018)
 Integrated care systems are a new type of even closer collaboration in which NHS organisations, local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.