Integrating care: policy, principles and practice for places
Health and care integration is not a new concept. It has been a constant and dominant policy theme for many years and has moved from pilots and programmes through voluntary partnerships of health and care organisations with no formal powers or accountabilities.
The Health and Care Act 2022 put integrated care systems (ICSs) on a statutory footing and provided a legislative framework, which moves away from competition in the NHS and aims to better support collaboration and partnership working.
But the Act is not the end goal. Rather, it is a touchstone on the integrating care journey and represents a new opportunity. Before the Act had passed, the government published a White Paper, which set out aims to go ‘further and faster’ with integration.
Integral to the success of this ambition is a ‘whole systems’ approach to public financial management. This is an understanding that outcomes can be significantly improved by working across organisational boundaries, and recognition that interconnectedness of partners involved and the greater impact they can have through closer collaboration.
The purpose of this report is to provide an overview of the changes as a result of the 2022 Act, what integration is trying to achieve, the wider landscape in the current climate and where we are now, as well as addressing some of the remaining challenges at place level.
What and why?
The renewed focus on integration presents a new opportunity for partners across the health and care sector to work differently. A more strategic, long-term focus on the social determinants of health and wellbeing, reducing inequalities and prevention should improve population health, but also help ensure that health and care services remain sustainable for future generations.
Taking a truly place-based and preventative approach could make a huge contribution to achieving the core purposes of ICSs and the triple aim duty set out in the 2022 Act.
Recommendations
Local level:
- Partners across systems/places should embrace the opportunity to truly work differently. Taking a more strategic, long-term and place-based approach encompassing the social determinants of health and wellbeing, reducing inequalities and with a focus on prevention could make a huge contribution to achieving the core purposes of ICSs and the triple aim duty, while helping to ensure that health and care services remain sustainable for future generations.
- All levels of local government have a key role to play in influencing the wider determinants of population health and wellbeing, as well as a deep knowledge of their places and neighbourhoods. Therefore, it is crucial that both upper-tier and lower-tier councils are engaged at place level and in the integrated care partnership (ICP)
Integration in the context of the wider landscape
Both the NHS and local government are facing enormous and growing challenges – existing pressures, recovery from the pandemic and the cost-of-living crisis sit among wider policy reforms and political and economic pressures. Such competing priorities can distract from and add tensions to the integration agenda.
There is a clear disconnect between immediate pressures and the longer-term investment required to focus on prevention and population health. Good financial management depends on consideration of the entire breadth of responsibilities over a long-term horizon to ensure outcomes and value for money are achieved. This requires certainty of funding and coherence of policy priorities.
Some areas of government policy remain misaligned with national integration policy. Developing complex workarounds drains resources and distracts from the goal of closer integration. The ideal solution would be to improve policy alignment within and across government departments. However, sharing experiences and improving understanding of potential workarounds would be a welcome first step.
Central government departments should lead by example and demonstrate an integrated approach to coordinating and clarifying policy priorities for the health and care sector overall. Otherwise, it is difficult to envisage how integration can progress 'further and faster' as expected.
Within this crowded landscape, a shared understanding among partners is essential. Openness and transparency about the priorities and pressures they face is key for cultivating relationships and trust, which partnerships are built on.
Recommendations
Central Government:
- Given the crowded landscape within which integration is taking place, government departments should lead by example and demonstrate a collaborative approach to co-ordinating and clarifying policies for integration and wider reforms across the health and care sector.
- There remain areas of national policy that are misaligned with integration. Ideally, policy alignment should be improved within and across government departments. However, sharing experience and understanding of potential workarounds would be a welcome first step.
- Future guidance on joint appointments between NHS bodies and local authorities should seek to resolve, or at least clarify, the misalignment of VAT treatment, which can act as a barrier.
All levels:
- Achieving the vision for integration requires long-term commitment and certainty of funding. A twin track approach is necessary to ensure services can deal with existing and immediate pressures, as well as making long-term investments to ensure services are financially sustainable and provide value for public money.
Shared outcomes
A focus on outcomes can highlight interdependencies between services and organisations and so help foster a shared vision and understanding in partnership working.
Good public financial management requires making evidence-based decisions on the allocation of public funds to outcomes and the ability to track and evaluate progress.
Government departments should work together to clarify priorities across national policy and develop a national outcomes framework that provides a single, coherent set of shared goals across the health and care sector, without adding a further tier of bureaucracy.
Case studies:
The report provides several examples of nations that have introduced such national frameworks. For example, the Scottish Government introduced the National Performance Framework (NPF) in 2007. The NPF is intended for the whole of Scotland, encouraging national and local government, businesses, voluntary organsiations and its residents to work together towards a shared purpose and values.
In addition, New Zealand introduced its first wellbeing budget in 2019, which aimed to shift the emphasis away from economic growth towards a more balanced view of the options for social, environmental and economic decisions and priorities.
Recommendations
Central government:
- An outcomes-based approach to integrating health and care must be backed by long-term political and financial commitment and must be based on realistic expectations of what can be achieved.
- Government departments should collaborate to develop a national outcomes framework that provides a single, coherent set of shared goals across the health and care sector, without adding a further tier of bureaucracy. The emphasis should be on local priorities reflecting national outcomes, not national performance metrics driving local activity.
Local level:
- Priorities, outcomes and associated metrics should be determined in the context of the national framework and based on evidence of local circumstances and need.
- Creating a link between resource allocation and outcomes would provide a clearer focus across partners and would assist in making evidence-based decisions on the allocation of funds, as well as the ability to track and evaluate progress and ensure value for money.
Place-based governance and accountability
Good governance in the public sector encourages better informed and longer-term decision making and the efficient use of public resource. It strengthens accountability for stewardship of those resources and results in more effective interventions and better outcomes for the population.
Several models have been proposed for place-based governance and accountability arrangements. The expectation is that all places will have adopted a model of accountability that meets these criteria and identifies a single accountable person by spring 2023.
Given the significant variation between places, their evolution is unlikely to proceed uniformly. This is not necessarily a function of their maturity but may be due to inherent structural factors. Thus, a ‘one size fits all’ set of criteria does not seem the most reasonable approach.
Case studies:
The report presents several case studies showing how places are establishing their own arrangements. In Greater Manchester, place-based leads (or SAPs) were selected for each of the ten places. When selecting SAPs, three options were considered, all of which are focused on local councils as the ‘leader of place’.
Similarly, NHS South East London Integrating Care Board (ICB) has agreed a principle of subsidiarity in determining roles and responsibilities across its system. To fulfil its mission, the ICB and wider system will rely upon place-based partnerships, working together to improve health and care for their communities.
Recommendations
All levels:
- A principles-based approach to governance and accountability arrangements in place-based partnerships (which could incorporate some minimum standards) would recognise the diversity of places and allow for adaptation as they evolve over time. Within this, it would be for each place to determine appropriate and proportionate arrangements and for others to assure themselves of their sufficiency.
Finance for place
The NHS and local government operate under vastly different funding and financial regimes. Fostering a shared understanding between partners is essential if they are to build the relationships and trust required to realise the aims of integration.
Current financial regimes and funding mechanisms do not support a whole system approach to improving population health and wellbeing with a focus on prevention. Achieving this will necessitate a more strategic and long-term approach to funding and financial planning.
Case studies:
There are various case studies in the report, showing how funding and finance mechanisms are being established at place level. These explore the experience of pooled budgets in Wales and Oxfordshire, as well as the use of aligned budgets with an underlying financial framework, in Greater Manchester.
Recommendations
Central government:
- The commitment to review Section 75 arrangements for pooling budgets and to produce further guidance is welcome. The proposed guidance should consider a broader view of how to mobilise resources across organisational boundaries to best effect, with a focus on removing associated complexities, which can act as a disincentive.
Local level:
- Partners should seek to foster a shared understanding of the different systems in which they operate and take an open and honest approach to the pressures they face. This is crucial to building the relationships and trust required for success.
- Delegation of functions and resources from system to place level could be underpinned by a place level financial framework. Again, such a framework should be based on principles, which can be adapted to suit local variation and circumstances.
Putting the principles in place
Developing a principles-based framework for place would not only allow for the significant variation but would also be flexible to enable arrangements to adapt and become more sophisticated as places mature and evolve. Such a framework should be informed by local circumstances and aligned to the ‘national ask’.
In developing such principles the CIPFA/ IFAC International framework: good governance in the public sector (2014) and the six principles of good public financial management from CIPFA’s Financial Management Code (2019) would be a good starting point. Further suggestions for principles in place are detailed in the full report and may include the following: shared vision; collaboration and partnership; transparency and openness; build on what works; and financial management and subsidiarity.
Given the evolution of places over time is unlikely to be linear, it will be helpful for places to identify where they are on this journey and chart a course for the progressive nature of integrated care in their locality.
Recommendations
All levels:
- A combined principles-based framework for place that incorporates robust governance, accountability and finance arrangements would provide flexibility to allow for adaptation as places mature and evolve. Such a framework should be for local determination and aligned to the ‘national ask’.
Local level:
- In developing a principles-based framework, places should identify where they are on the integration journey and chart a course for the progression of their locality in the future.
The role of the finance professional
Bringing together services to improve population health needs to be supported by long-term planning and stripping away the barriers that prevent closer alignment of services. The finance function is a critical enabler of closer integration, helping resources to move freely and so empowering change.
This requires strong financial and collaborative leadership from CFOs in NHS bodies and local government, both in shaping the finance and governance arrangements in their local area to ensure good public financial management and in promoting and supporting the role of the finance function.
Recommendations
Local level:
- CFOs in the NHS and local government should play a critical role in providing collaborative financial leadership, both in shaping the finance and governance arrangements in their locality to ensure good public financial management and in promoting and supporting the finance function as key enablers of closer integration.
The full report includes many useful case studies and recommendations.
It can be downloaded on CIPFA's website.
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