Government response to the House of Commons Health and Social Care Committee’s seventh report of session 2022 to 2023 on ‘Integrated care systems: autonomy and accountability.’
The document goes through each of the recommendations outlined by the H&SC Committee Hewitt Review under six themes:
- Theme 1: targets and priorities for ICSs
- Theme 2: autonomy, leadership and support for ICSs
- Theme 3: ICS governance, accountability and oversight
- Theme 4: assessments and reviews of ICSs
- Theme 5: prevention and promoting health
- Theme 6: finance and funding
Read the full document here
Theme 1: targets and priorities for ICSs
Summary of recommendations
Ensuring targets are based on outcomes and seek to meet the ICS four objectives. There needs to be clear mechanisms that ensure national and local priorities are met and that greater co-development can be achieved. The role does NHSE and DHSC have in system scrutiny.
Summary of response
DHSC and NHSE have outlined that there is national importance where they will set future trajectory targets, whilst enabling local systems to facilitate local targets. DHSC recommit to narrowing the gap into health life expectancy (HLE).
DHSC further recognise the benefit of focusing on small priorities. The reduction of NHS objectives to 31 from 2023-2024 will be further reflected in the forthcoming mandate to NHSE.
DHSC further outlines the four objectives of an ICS and be enabled to set a focus of number locally co-developed. To support this work the Department is committed to publishing a shared outcomes toolkit to support the development of local outcomes.
The response goes on to discuss mechanisms to ensure national and local progress is made towards priorities and plans. It notes that CQC will consider how well each ICS is addressing strategic issues, and will continue to develop a sampling based approach to look at the effectiveness of place-based arrangements.
On NHSE, the Government outline that it has a legal duty to annually assess the performance of each ICB in each financial year and publish a summary of its findings, taking into consideration how well they are carrying out their statutory duties, as outlined in the NHS oversight framework 2022-2023. Health and Wellbeing Boards within this process.
On ICBs, ICPs and local authorities arrangements, DHSC has outlined that they plan to refresh their July 2022 guidance on how these entities will be organised. Furthermore the Office for Local Government (Oflog) will also bring together meaningful data to provide a transparent and authoritative source of information about the performance of local Government.
DHSC finalises this section by noting that the above measures will allow for the right balance between clarity of national requirements and local innovation and flexibility.
Care England Comment
Whilst it is positive to see the recommitted by DHSC to promote local priorities to match local outcomes, the Department does not explicitly outline how they will ensure how they will keep ICSs ‘in-check.’ Whilst co-development is mentioned within their response, it is not specific in who should be included (i.e. what H&SC organisations should be considered for co-development discussions) co-development. It will be interesting to see how DHSC refreshes the July 2022 guidance and reflects the need to further engage with the adult social care sector, particularly regarding involvement in decision making, as the Hewitt Review outlines.
Theme 2: autonomy, leadership and support for ICSs
Summary of recommendations
DHSC should take measures to ensure that correct mechanisms are in place that allow greater collaboration between NHSE, LGA, NHS Confederation and NHS Providers to ensure leadership support. There needs to be a greater national effort to facilitate peer reviews, as done so by the LGA. There needs to be greater co-production between ICBs, NHS Confed. and NHS Providers.
Summary of response
DHSC reconfirms that it is working with NHSE to ascertain whether ICS leaders are best equipped to lead their systems in a fully integrated way. The response further outlined that a senior advisory group across health and care has been brought together to advise/plan a three year roadmap for leadership and management support in response to the Hewitt and other reviews.
DHSC reiterates that NHSE has statutory accountability for oversight of ICBs and in exceptional circumstances NHSE will intervene directly with providers. The response agrees that a national peer review should take learnings from the approach developed by the LGA.
DHSC finalises by referring back to the operating framework and how NHSE aims to co-create and secure co-ownership of strategy, priorities and plans within the NHS and with wider partners.
Care England’s comment
It is positive to see that the Government will be setting up a senior advisory group that will bring together health and social care leaders from the whole sector. Care England will look to hold DHSC to account to ensure that representation of the adult social care sector is established and appropriate.
The reiteration that NHSE has statutory accountability for ICBs is not surprising. What is lacking within this section is how can partners, in particular adult social care providers, can ensure that they are represented within co-production.
Theme 3: ICS governance, accountability and oversight
Summary of recommendations
The need for the Secretary of State to set out how MPs can hold ICSs to account. Greater understanding of the structure of each ICS to be gathered, including ICB membership and specific role of their members. There needs to be greater clarity from NHSE as to what ICSs should expect when monitoring partnerships.
There needs to be clear action from DHSC to work with ICSs, CQC and NHSE to resolve poor partnership working, particularly with adult social care.
A new high accountability and responsibility partnership should be created and developed by ICSs and partners with DHSC and DLUHC. NHSE should also co-design a clear maturity pathway.
Summary of response
DHSC notes that ICSs have greater responsibilities and can address local matters to meet local needs to a greater extent than previous integration attempts. It notes that local Government are held accountable through democratic measures. ICSs are help accountable through a balance of local Government and through the NHS, which is in turn accountable to Government and Parliament.
The Oflog will enable DHSC to have a holistic overview of adult social care representation within ICS and each system’s performance. Furthermore, DHSC note that the CQC’s assessments of ICSs will provide further assurance to the public and Parliament.
DHSC notes that it will not record ICB membership centrally as that will be duplicating workstreams. It further outlies that where ICBs propose a change to their board membership, it should be discussed with NHSE. The DHSC does not further outline how ICBs should consider how best to host the representation of adult social care, but they do note that they will continue working with DHSC to ensure measures in place are working. On partnership working, DHSC outlines that NHSE does not have the remit to consider the effectiveness of wider partnership working.
The DHSC refers to the Health and Care Act 2022 as the importance of all partners (including social care providers) to work together and provide more joined-up care. CQC will have a pivotal role to play in this regard through their ICS assessments.
DHSC focuses on promoting the independence and autonomy of ICSs and the infancy of ICBs/ICPs. The Department does outline however that further work needs to be undertaken to consider how partnerships of the kind described in the Hewitt Review might work in practice.
Care England comment
It is positive to see that there is acknowledgement that further work must be facilitated to ensure greater collaboration between sectors. However, it is disappointing that DHSC will not facilitate greater oversight to ensure meaningful collaboration, representation and co-production between all system partners.
Whilst Care England understands the importance of local autonomy. Whilst many ICBs and ICPs have made efforts to ensure provider representation and involvement within decision-making, it is not always consistent, nor sufficiently representative of the sector.
Theme 4: assessments and reviews of ICSs
Summary of recommendations
There must be clarity on the ratings CQC will use to assess ICSs, DHSC has an urgent role ensuring this is materialised. To ensure that duplication of assessments is avoided, DHSC has a responsibility to review existing regulatory assessments for ICSs.
Summary of response
DHSC acknowledges and supports the vision set out within the Hewitt Review and how best to approach ICS ratings.
On the accountability of ICBs, NHSE is responsible for undertaking annual performance reviews. CQC will test working arrangements with NHS England during its pilot assessments.
Care England comment
Whilst, understandably, DHSC must not become too involved within the independent process for determining how ICSs will be assessed, it is disappointing that the response to the recommendations does not address the urgent matter of the pilot being facilitated in three ICSs or that the ratings are not yet finalised.
Care England expects health partners to be treated with the same level of scrutiny as adult social care, and it is disappointing that DHSC does not recognise nor promote this.
Theme 5: prevention and promoting health
Summary of recommendations
NHSE should provide an update on whether they intend to refresh their 2019 Long Term Plan and how prevention sits within this plan. DHSC should also publish the shared outcomes framework and how ICSs should implement this. DHSC should also review the prevention agenda, and ICSs should increase their prevention budget by at least 1% over the next five years. The Government should establish a health, well-being and care assembly and a national integrated care partnership forum.
Summary of response
DHSC outlines the importance of ICBs needing to reduce health inequalities. The major conditions strategy will aim to alleviate pressure on the health system and support the Government’s objective to increase healthy life.
DHSC agrees that it is correct for local priorities to align with national priorities. For social care, Adult social care and public health will continue to have their priorities set via the Adult Social Care Outcome Framework and the Public Health Outcomes Framework.
DHSC outline that it is important to grant ICSs the freedom to create the architecture and governance for their ICP and ICB that enables them to best serve their population. The Government further agrees that the NHS should be shifting towards a more focused prevention agenda over time. To support this, NHS England and DHSC will work closely with ICSs, local government partners and NICE to develop practical information and evidence to support local investment decisions.
DHSC notes that more work must be facilitated to implement a national integrated care partnership. DHSC does note that there needs to be an efficient way of convening ICPs at a national level without duplicating current efforts.
Care England comment
Prevention has been a key discussion point for Care England’s conversations with ICSs and their partners. Notably, it has been mentioned to Care England that the current push to shift ICB budgets by 1% towards prevention is simply not enough.
Social Care will play a pivotal role within the prevention agenda, and the data currently stored by providers will be essential to understanding how long-term conditions, such as dementia, can be prevented. Through working with ICSs, Care England will continue to promote the utilisation of the adult social care sector to help address health inequalities, both short and long-term.
Theme 6: finance and funding
Summary of recommendations
Ensuring that long-term understanding of finances is maintained and is sustainable for ICSs. Ending small in-year funding pots will help achieve this and give local systems greater flexibility to determine service allocations and appropriate payment mechanisms. DHSC should review the funding and commissioning arrangements for Healthwatch.
DHSC, DLUHC and NHS England should align budget and grant allocations for local government (including social care and public health and the NHS). NHS England should ensure that systems are able to draw upon a full range of improvement resources to support them to understand their productivity, finance and quality challenges and opportunities.
Summary of response
DHSC outline that in advance of the publication of the 2023 to 2024 local government finance settlement (LGFS), DLUHC published a policy statement in December setting out forward notice of measures expected to be maintained into 2024 to 2025. The government’s intention was for this to support councils’ budget setting processes by giving them additional, multi-year certainty over their funding levels. For social care, this included setting out the adult social care precept referendum principle for 2024 to 2025 and reiterating the increase in grant funding as set out at the Autumn Statement.
On ‘in-year fund pots,’ DHSC note that these measures are often required to address certain priorities, such as the £500m for winter discharge for December 2022 – March 2023. Future discharge funds have been announced, and DHSC note that funding may be ringfenced for a particular purpose. DHSC does recognise that should additional reporting requirements accompany future funding of this type, they should be proportionate.
DHSC agrees in principle, that systems should be provided with sufficient flexibility to determine allocations for services and appropriate payment mechanisms, particularly to meet the needs of their local population, but note that flexibility to adapt to situational circumstances is also required.
DHSC accepts that effort should be made to establish standardised reporting across ICS organisations and local authorities to support public spending on key policy areas. This will need to be explored further.
DHSC is committed to facilitating greater health and social care service integration and wants to encourage partnerships through pooled budgets. It is critical that ICSs are able to draw on a range of resources to support and incentivise improvement.
Care England comment
A holistic understanding of funding has long been an issue within adult social care. Care Providers are unable to plan financially efficiently due to delayed uplifts. Whilst it is positive that the discharge funds for 2023/24 and 2024/25 have been announced, the actual allocation of these funds or conditions as to how they are spent has not been. For health and social care to be maintained at a sustainable rate, and plan for the prevention agenda, there needs to be greater foresight into future funds.
Equally on standardised reporting, whilst focusing on internal reporting within an ICS, should also be enacted for NHS-commissioned services. Non-standardised reporting leads to a greater admin burden and slows down the payment rate. External standardisation should also be considered if there is to be internal standardised reporting.
On encouraging partnership, Care England encourages DHSC to further promote the need to work and engage with adult social care partners. Shared learning and best practice can only be achieved when all stakeholders are involved.
Additional Hewitt Review recommendations
Digital and Data
Within the Hewitt Review, there were significant recommendations regarding Digital and Data. The Department of Health and Social Care uses this section to primarily reiterate the policies that are included within the Data Saves Lives Strategy. Policies such as these include digitising 80% of the adult social care sector by 2024.
Primary and social care
Within this section, the Government responds to the recommendation for there to be a social care workforce strategy that compliments the NHS workforce plan.
DHSC outlines that social care has a significantly different structure to the NHS. Whilst the Government does not commit to a workforce plan, it notes that the workforce is a central feature within the 10-year vision plan (People at the Heart of Care).
DHSC notes that ICSs and local government need to work together to further ensure they take their next steps twowards developing a joint and integrated workforce. They re-outline that over the next two years, £250m will be spent on:
- launch a new care workforce pathway for adult social care, which will support development and provide a career structure. The first part of the pathway, focusing on those in direct care roles, will be published in autumn 2023.
- funding for hundreds of thousands of training places to support development and progression. This funding will give care workers the opportunity to develop and improve skills to support them to deliver high-quality, personalised care. This training offer will include:
- investment in leadership, dementia, digital and learning disability and autism training
- funding for continued professional development for regulated professionals
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