Health & Social Care Committee: Integrated Care Systems: Autonomy & Accountability

Health & Social Care Committee

Integrated Care Systems: Autonomy & Accountability

(28 March 2023)

The report can be found here and our written submission here.

Summary

• Notes optimism about Integrated Care Systems (ICSs).
• Notes concerns that potential will not be realised; serious lack of clarity in some areas.
• Collaborating well with partners will be the make-or-break factor in determining the success of ICSs – it is vital that social care is not forgotten, and that ICSs do not become too NHS centric.
• To support collaboration, NHS England and DHSC need to adapt their approach, with NHS England needing to move away from its centralised “command and control” approach.
• Right that ICSs outcomes should be set out, but vital that Gov and NHSE do not dictate how ICSs should deliver these outcomes to protect the intended flexibility of ICSs. Targets must be outcome-based.
• ICS focus on longer-term issues, such as population health and prevention, must be balanced with short-term, operational challenges. DHSC and NHSE must make efforts to ensure ICSs have capacity to focus on these long-term issues. Recommendation of refreshed version of NHS Long Term Plan.
• Concern that NHSE told ICBs that their Baseline Running Cost Allowance will be “subject to a 30% real terms reduction” by 2025/26 and Committee is conscious of the impact this will have on ICSs’ ability to meet their aims and objectives.

Introduction

• Committee inquiry launched in July 2022 to scrutinise the way proposals had been realised.
• Gov announced independent review of ICSs, led by Rt Hon Patricia Hewitt, during inquiry.
• ICSs founded in difficult landscape – challenges around workforce, funding, care backlogs and pressures on acute and social care services. DHSC and NHSE will need to be constantly mindful of how immediate pressures might crowd out longer term work.
• Variety of partners will ultimately need to come together to ensure ICSs are successful, beyond those that fall under the responsibility of the DHSC. If there is to be true integration, policymakers need to always be aware of the importance of all partners.
• There needs to be a level of accountability and performance management, but this has to be done in a way that does not infringe on the flexibility at the heart of the design of ICSs.

1. Autonomy

New ways of working: the relationship between DHSC, NHSE and ICSs

• Desire that NHSE and DHSC avoid “micromanaging” ICSs.
• Witnesses were cautious about the new framework, suggesting that for it to deliver what it promises, there would need to be cultural change within the NHS.
• ICSs offer a new way of working across health and social care – they encourage collaboration with a range of partners and a focus on what matters to their local populations. This premise needs to be balanced within a national service, funded by taxpayers and accountable to Parliament. It is therefore right that DHSC and NHS England set some of the priorities that ICSs should be working towards.
• However, if ICSs are to realise the ambitions that have been set for them, it is vital that DHSC and NHS England do not dictate how ICSs should deliver those outcomes.
• Recommendation: Targets for ICSs set by DHSC and NHS England should be based on outcomes. Use of greater prescription for how targets are achieved should be done sparingly.

Setting and pursuing priorities: protecting space for local priorities

• It is encouraging that in guidance relating to ICSs, both the Government and NHS England have recognised the importance of leaving space for local priority setting.
• Feb 2022, Gov published Joining up care for people, places and populations. The idea of this shared outcomes framework has been broadly welcomed. However, caution was expressed about the implementation of any shared outcomes framework.
• We welcome the clear references to local priorities within NHSE guidance for ICSs and DHSC’s proposed shared outcomes framework. We hope that, in the years to come, this focus on local priorities will be maintained. However, we share concern about the tension between local needs-based strategies and a national standardised service.
• Recommendation: DHSC should explain the mechanisms that will ensure that progress is made against local priorities.
• Recommendation: DHSC should publish, as soon as possible, the proposed shared outcomes framework and more information about how and when ICSs should expect it to be implemented.

Ensuring a focus on the long-term challenges

• ICSs present an opportunity to address immediate operational pressures, while also looking to the longer term: improving health outcomes, addressing health inequalities, prevention.
• The evidence we have received highlights the scale of the challenge that ICSs will face if they are to balance immediate pressures with longer-term work.
• There is a clear risk that short-term, acute pressures will dominate ICS capacity, resources and leadership headspace, limiting the true flexibility of ICSs. Active effort from DHSC and NHSE is needed to ensure ICSs retain the space they need to focus on matters like public health and prevention.
• Recommendation: NHSE should provide an update on whether they intend to refresh their 2019 Long-Term Plan and, if so, when. Any update to the Long-Term Plan must put prevention and long-term transformation at its heart, empowering ICSs to pursue these priorities and giving them the confidence that they have the necessary backing from the Government and NHS England. This should also apply to the Government’s pending Major Condition’s Strategy.
• Improving outcomes in population health and healthcare is one of the four core purposes of ICSs. Despite this, there is no mandated representation for public health professionals on Integrated Care Boards.
• Recommendation: To guarantee a continual focus on the prevention agenda, all Integrated Care Boards should ensure they include a public health representative, such as a public health director or public health lead. In 12 months, DHSC should conduct a review to understand the extent to which this is happening.

Short-term funding pots

• One of the key challenges that impacts on an ICS’s ability to look to the longer-term relates to Government funding cycles. Short-term nature of fundings is challenging. While funding is welcome, we note that the nature of its allocation and monitoring may lead to the unintended consequence of restricting the autonomy of ICSs.
• The four key purposes of ICSs are all dependent on taking a long-term approach – ICSs need to be supported to make long-term decisions and have as much certainty as they can about upcoming funding.
• Recommendation: DHSC must set out how it intends to inform ICSs about funding that will be available to them further in advance, and any decision to give that information must be made in plenty of time to support ICS preparations for winter 2023/24.

Developing from an organisation to a system leader

• Leadership of and within ICSs is critical.
• System leadership is different to organisational leadership and ICS leaders, as well as leaders at other levels, need support to develop skills to make the most of the opportunities and to ensure ICSs do not become too NHS centric.
• Recommendation: The Government and NHSE should set up and fund an ICS leadership development programme, specifically targeted at supporting leaders of and within ICSs to develop the skills required to be successful system leaders.

2. Accountability

What are ICSs expected to achieve?

• While the four core purposes of ICSs are important overarching aims, it is unclear what specific benefits will be achieved within these purposes and how ICSs will be measured on progress.
• We share concern about the lack of clarity around what ICSs are expected to deliver within their core purposes. While we are conscious of, and agree with, the need to avoid micromanaging ICSs, we believe that DHSC needs to provide additional clarity about what exactly ICSs are expected to deliver.
• Recommendation: Following engagement with ICSs, DHSC and NHSE should issue guidance with additional detail on what ICSs are expected to achieve within each of the four core purposes (focus on outcomes).
• MPs should be supported to directly hold their local ICSs to account for the service they provide to constituents, without having to rely on an assessment provided by local health and care leaders. We welcome the Secretary of State’s desire to empower parliamentary colleagues to hold their local ICSs to account through transparency on ICB performance data.
• Recommendation: The Secretary of State should set out further detail about how he intends to empower MPs to hold their local ICSs to account and what performance measures he envisages being available to support this.

Partnership working: at the heart of ICS design

• ICSs have been designed to be a partnership of organisations – to meet their duties, ICSs need to reach beyond the NHS to bring together local authorities, Voluntary, Community and Social Enterprise (VCSE) organisations and other local partners.

The ‘voice’ of social care

• Concerns about the exclusion of adult social care in new systems, and the risk of ICSs becoming ‘NHS-centric. Care England wrote: “The concern for [Adult Social Care] providers is that ICBs will merely be a reworked version of CCGs [clinical commissioning groups]; suffering from an NHS centric focus that excludes the needs and concerns of the care sector”.
• Given concerns about exclusion, some of the evidence called for ICSs to be held accountable to a greater extent for partnership working, in particular with the social care sector.
• Partnership working is fundamental to the design of ICSs and will be the make-or-break factor in their success. It is unclear how partnership working will be monitored. It is also unclear how ICSs will be held accountable for partnership working, particularly if problems arise.
• Recommendation: NHS England should provide more clarity about what ICSs should expect in terms of the monitoring of partnership working and how this will be assessed in ICB annual assessments.
• Recommendation: DHSC, working with ICSs, should clearly set out what action could be taken, be that by the CQC, NHS England or others, to resolve issues of poor partnership working, in particular with adult social care.

Which skills and specialities make up ICBs?

• The Health and Care Act 2022 sets out the minimum membership of Integrated Care Boards (ICB). The Government said that it sees the ICB membership in the legislation as the “baseline” and it does not want to “over-prescribe”. However, ministers have also said that the minimum membership requirement could be expanded through regulations if needed at some point in the future.
• We heard calls for additional mandated representation, in particular for clinicians and social care providers. Care England and the National Care Forum highlighted the need for greater involvement of the social care sector, beyond local authorities and NHS commissioners. Professor Vic Rayner, Chief Executive at the National Care Forum, explained to us that there is not “full representation” of adult social care if that representation is only through local authorities as local authorities are “largely commissioners”.
• We are sympathetic to the concerns that have been raised with us about the exclusion of expertise. However, we are also sympathetic to the Government’s intention to give ICSs flexibility when determining which professions are most relevant to their local needs. Our concern is that it is unclear how the Government will monitor and evaluate whether its approach is the correct one.
• Recommendation: DHSC should centrally gather information relating to the membership of ICBs, including the specific role of members and their area of expertise, by 1 October 2023.
• Recommendation: Once the data is gathered, DHSC should review it with a view to understanding whether the policy of keeping mandated representation to a minimum is producing the intended results and whether any specialties are especially under-represented. They should report the outcome of this work, and whether any further mandating is required, to the House.

Supporting the involvement of patients, their carers and representatives

• The involvement of patients and their carers is a key part of the new ICSs. As set out in the Health and Care Act, each ICB has a duty to “promote involvement of each patient… in decisions which relate to the prevention or diagnosis of illness in the patients or their care or treatment”. This also includes their carers and representatives.
• Healthwatch was established under the Health and Social Care Act to “understand the needs, experiences and concerns of people who use health and social care services and to speak out on their behalf”.
• The core purposes of ICSs will not be met without good patient and carer involvement.
• Given the new expectations that have been placed on Healthwatch organisations across the country, we believe this is a good opportunity to consider their funding and commissioning arrangements.
• Recommendation: DHSC should therefore review the funding and commissioning arrangements for Healthwatch, with a view to ensuring they are fit for purpose within the context of new ICSs, and support Healthwatch to have a clear voice. The outcome of this review should be reported to the House.

What will CQC assessments look like?

• Section 31 of the Health and Care Act 2022 places a new duty on the CQC to review, assess and undertake ratings of each ICS. CQC assessments must consider leadership, the integration of services and the quality and safety of services. The legislation also gives the Secretary of State powers to set additional objectives and priorities for what the CQC assesses.
• The CQC has recently developed a new single-assessment framework, which they will use to assess not only ICSs, but also providers and local authorities.
• The methodology that the CQC has built does allow ICSs to be rated and CQC’s interim guidance sets out how this could work. However, Kate Terroni told us that it is a “decision for the Government to make” as to whether ICSs will be provided with a publicly available rating.
• We were also interested to learn of the CQC’s approach when an ICS may include a poorly performing provider. Kate Terroni explained that ICS assessments would not be an aggregation of provider ratings.
• Given that the CQC will have the legal powers to conduct assessments from April 2023, it is concerning that there are still outstanding questions that the Government needs to provide clarity on – particularly around any priorities DHSC may have for the assessments, and whether the CQC will be expected to provide ratings.
• Recommendation: DHSC should urgently provide the CQC with its decision on ratings and any priorities it would like the CQC to focus on. It should also communicate to ICSs what methods will be used to address any areas of concern that assessments might raise.
• Recommendation: DHSC and NHSE should review existing regulatory assessments for ICSs with a view to ensuring there is as little duplication as possible.