NHS guidance and expectations in relation to partnership and engagement
The 1 July 2022 saw the formal enactment of the parts of the Health and Care Act 2022 which put the 42 Integrated Care Systems (ICSs) across England onto a statutory footing. Clinical Commissioning Groups (CCGs) have been abolished with their commissioning powers transferred to the new ICS bodies.
The NHS and local government colleagues have produced a number of publications and interim guidance documents setting out how it expects NHS leaders, local authorities and partner organisations to operate in the new systems.
The intention behind these Integrated Care Systems is to move towards joined-up health and care, to give people the support they need, in the right place and at the right time. The partnership model is intended to bring together health and social care providers and commissioners of NHS services with local authorities and other partners, to collectively plan health and care services across specific geographical areas across the country, and tackle health and wellbeing inequalities.
Whether this can be achieved depends entirely upon the willingness of these systems to proactively involve and meaningfully engage social care providers.
It is very clear that ICSs are intended to be a delivery vehicle for the government’s wider reform plans for social care and health. Both the Adult Social Care and the Integration White Papers describe ICSs as the mechanism for delivering some of the government’s ambitions such as delivering digital transformation, innovation and housing.
With ICSs as the lynchpin of the reform agenda and the ‘Place’ level being the focus of integration, it is important social care providers are in turn recognised as strategic delivery partners in this. And of course, integration alone isn’t a panacea – it is no substitute for long term, sustainable funding.
The NCF have produced an overview of ICSs and links to useful guidance.
The ICS guidance to date is largely permissive in relation to how ICSs achieve engagement with social care providers in governance, decision making and strategic planning. This means that ICSs may vary greatly in their level and consistency of engagement with social care providers and therefore the NCF has created a range of key messages to support your local discussions
Key messages for ICB Chairs and Chief Executives
Social care is a critical part of the health and care system, providing vital services within local care systems. Social care providers need to have their voice heard at the top table of ICS decision making and planning as they are key to helping deliver the population health and care outcomes for which the ICS is responsible:
Millions of people across the country draw on care & support from social care providers and care providers employ the majority of the overall social care workforce which currently sits at 1.54 million according to Skills for Care’s annual workforce report. Social care providers play an integral part in the lives of the people they support and therefore failure to actively involve social care providers in ICSs will not deliver the population care and health outcomes which the ICS is responsible for. Involvement of managers from across the social care provider sector in the national leadership programme for skills for transformation and partnership is also essential in recognising them as key strategic leaders within ICSs.
The Local Authority voice is only one aspect of social care in an ICS and social care providers bring valuable expertise in their own right:
It is important to remember that the Local Authority voice, data and knowledge alone cannot equip the ICS planning processes with a comprehensive view of the social care offer. Local authorities only commission a section of the sector. It is of concern that the Integration white paper conflates LAs with adult social care and does not recognise the integral, distinct role of care providers. The white paper, People at the Heart of Care, emphasises the importance of shaping healthy and diverse social care markets. It acknowledges that currently there is not sufficient encouragement for new, innovative, community-based organisations that have the potential to give people greater choice, independence and wellbeing. Social care providers, especially not for profit providers, are deeply rooted in their local communities. They bring hugely valuable expertise in meeting the current and future needs of their wider communities, including those who fund their own care and rarely have contact with their LA. They are an essential partner in strategic planning.
Improving services and outcomes for local people is a key deliverable for ICS:
This includes preventative care and support services to enhance health and wellbeing and improve quality, experience and access for those who need this support. An ICS that fails to engage with their care and support providers will miss the opportunity to harness the insights and experience of social care providers, is likely to lack credibility across the ICS footprint and seems unlikely to succeed in delivering service improvements. The NHS guidance relating to partnerships with the VCSE emphasises that the VCSE sector has a long track record in promoting engagement and finding creative ways to improve outcomes for groups with the poorest health, making it an essential partner in combating the inverse care law. The inverse care law highlights that disadvantaged populations need more healthcare than advantaged populations, but tend to receive less.
Responsive service design and new models of care:
Planning which capitalises on the agile solutions which social care providers are highly experienced in delivering will contribute to more and better joined-up care. Social care providers can bring to the table long standing experience in mobilising assets and delivering services around the needs of people who use services, carers and communities, within constrained budgets. The white paper, People at the Heart of Care, announced that more than £70 million will be allocated to increase the support offer across adult social care which includes assisting local authorities to better plan and develop support and care options available.
Similarly, £30m is being provided to help local areas innovate around the support and care they provide in new and different ways. It is essential that social care providers are at the table to inform ICP strategies when considering options and opportunities available. The collective response to the Covid-19 pandemic has demonstrated how innovation can address longstanding issues, and how integration can work well when funding is invested and budgets are pulled together. If ICSs don’t have the conversation with social care providers, ICSs will never know the potential! The Integration White Paper acknowledges the power of pooled budgets and resources and has announced a review of Section 75 (NHS Act 2006) and other ways of ‘aligning’ resources between LAs and NHS. It is important that people who draw on care and support are front and centre with social care providers in helping design services in collaboration with, alongside commissioners. Only then will we see services which are truly person centred and which allow people to move seamlessly between healthcare and social care.
Expertise in prevention and in meaningful dialogue with people and communities:
Social care providers also bring expertise in the use of preventive approaches. These embedded ways of working will help to deliver outcomes required of the ICS relating to population health and tackling inequalities. The well-established and trusted relationships, which many social care providers have with local communities, will assist the ICS to have a more direct and ongoing dialogue with communities and people. This will not only highlight issues but also contribute to ensuring the solutions will being real change.
Joint ICS health & care workforce planning:
The crisis in the health and social care workforce can only be addressed if the recruitment, development and retention of staff is approached in a joined-up way, with meaningful collaboration with front line social care providers. This is absolutely essential to ensure the ability to respond to new requests for care, maintain the existing provision of care and support and to work together in one system to respond to the increasingly complex needs of the local population. The Integration White Paper restates the importance of joined-up workforce planning at Place level. It is imperative that this extends across entire systems and that providers are regarded as strategic partners in helping deliver this joined-up workforce alongside NHS and LA colleagues.
Harnessing the power of technology & intelligence in better planning and delivery:
Supporting the digitisation of the sector will enhance quality and joined up delivery of care and support. Improved collection and sharing of data and intelligence will inform effective planning, assist with measuring system outcomes and provide evidence for CQC assessment requirements. We must harness learning between sectors as well as establishing meaningful strategies on developments in digital care records and data sharing to inform system-wide workforce planning. The Integration White Paper sets out a series of ambitions to digitise social care to enable the sharing of data across the health and social care system for intelligence purposes as well as coordinating people’s care and the workforces. Innovation and the insights drawn from data will also lead to new models of care and provide the data to support an understanding of population health, including unmet need and disparities. The timescales in the white paper to do this are very ambitious and so it is even more important that social care providers are included in the process of ICS finalising their Digital Investment Plans by June 2022, if the ambitions are to be ultimately met. The main ambitions are outlined in Appendix B.
ICS architecture solutions
To ensure a robust social care voice within the ICS architecture we recommend a social care non-executive director on the Integrated Care Board who would bring expertise when planning and commissioning services and allocating funds to deliver the Integrated Care Strategy. This NED should also have a role in championing and overseeing the social care provider voice across the decision-making forums in each of the ICS tiers. They would support the board in developing metrics that report on the aspects of the CQC assessment framework which relate to improving public health and tackling health inequalities.
ICS place & neighbourhood level arrangements:
Social care providers must be embedded in decision-making forums at place and neighbourhood level because it is at these tiers that the real operational change will be led. Guidance emphasises the importance of subsidiarity with local partners developing local plans to meet local needs.
The LGA and NHSE Thriving Places implementation guidance relating to place-based partnerships, states that ‘while it will be for local partners to agree the appropriate organisations and individuals to be included in the place-based partnership arrangements, they will do well to consider how they will include representation from —— social care providers.’
The document refers to a specific recommendation made by the LGA, NHS confederation, NHS providers et al in Shifting the Centre of Gravity: ‘place based systems should be established or amended following local discussion and considering the role of all the partners who contribute to health and care in a place, including housing, employment and training, and emergency services.’
Other guidance also focuses on the importance of connecting housing with health and social care. The types and range of housing solutions delivered by social care providers and their responsiveness in adjusting to changing needs must be understood and factored into pathway planning. They are also essential to the success of the White Paper’s reform proposals.
At present, many pathways of care are disjointed and there is not a consistent and robust approach for joint working between sectors. The Integration White Paper acknowledges this and gives the following as a definition for successful integration:
“Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole. Everyone should receive the right care, in the right place, at the right time. Our vision is that integration makes a significant positive impact on population health through services that shift to prevention and address people’s needs promptly and effectively; but it is also about the details and the experience of care – the things that often matter most to people, carers and families.”
Membership of decision-making forums within the ICS architecture will also improve the understanding of the role, range and flexibility of social care providers
Note appointments to the positions of chair and Chief Executive are under way. The list of appointments are on the NHSE website.
The ICS Guidance on partnership with the VCSE
This may also be of use/ interest to NCF members.
Below are some important statements from the ICS implementation Guidance on partnership with VCSE which ICB Chairs and ICB CEOs might usefully be reminded of in your discussions with them regarding your role in the ICS architecture.
- The VCSE sector is a key strategic partner within the ICS with an important contribution to make in shaping, improving and delivering services, and developing and implementing plans to tackle the wider determinants of health
- VCSE partnership should be embedded in how the ICS operates, including through involvement in governance structures in population health management and service redesign work, and in system workforce, leadership and organisational development plans.
- VCSE guidance states that by April 2022, ICBs are expected to have developed a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making arrangements, ideally by working through a VCSE alliance to reflect the diversity of the sector——Partnership arrangements should include agreed ways of working such as memorandum of understanding and sets of principles This timescale is likely to slip due to the pushback of the ICB go-live date to July 2022
The guidance relating to working with people and communities sets out 10 principles which should be considered in the preparation of Integrated Care Boards’ constitutions outlining arrangements for working with people and communities. (See Appendix A)
The following has been taken from ICS Implementation guidance on working with people and communities.
The principles that follow have developed from work with systems and build on those that appear in the ‘Working with people and communities’ section of the ICS design framework. They should be considered in the preparation of ICB constitutions outlining arrangements for working with people and communities to create a golden thread running throughout the ICS, whether activity takes place within neighbourhoods, in places or across whole system geographies.
- Put the voices of people and communities at the centre of decision-making and governance, at every level of the ICS.
- Start engagement early when developing plans and feed back to people and communities how their engagement has influenced activities and decisions.
- Understand your community’s needs, experience and aspirations for health and care, using engagement to find out if change is having the desired effect.
- Build relationships with excluded groups, especially those affected by inequalities.
- Work with Healthwatch and the voluntary, community and social enterprise (VCSE) sector as key partners.
- Provide clear and accessible public information about vision, plans and progress, to build understanding and trust.
- Use community development approaches that empower people and communities, making connections to social action.
- Use co-production, insight and engagement to achieve accountable health and care services.
- Co-produce and redesign services and tackle system priorities in partnership with people and communities.
- Learn from what works and build on the assets of all ICS partners – networks, relationships, activity in local places.
- Each ICS must have a functional and single health and adult social care record for each citizen by 2024,
- To achieve 80% adoption of digital social care records among CQC-registered social care providers by March 2024. Government will ensure that within six months of providers having an operational digital social care record in place, they are able to connect to their local Shared Care Record, enabling staff to appropriately access and contribute to the record
- A suite of standards for adult social care to enable providers across the NHS and adult social care sector to share information, starting with the consolidation of existing terminology standards by December 2022. A roadmap for this will be published in April 2022.
- Data to support an understanding of population health, including unmet need and disparities, should be fully shared across NHS and local authority organisations, to allow ‘place boards’ or equivalents, and ICSs to plan, commission and deliver shared outcomes, including public health and prevention services.
- Each ICS will implement a population health platform with care coordination functionality that uses joined up data to support planning, proactive population health management and precision public health by 2025.
- By March 2024, over 20% of care homes will have acoustic monitoring solutions or equivalent care tech in place.
- An ‘ICS first’ approach. This means encouraging organisations within an ICS to use the same digital systems, making it easier for them to interact and share information and providing care teams working across the same individual’s pathway with accurate and timely data.
- The inclusion and transparency of workforce, operational capacity, and financial data across an ICS can also support better use of scarce resources, and improve productivity