Creating a sustainable healthcare system

Health iStock 000005083391XSmall 146x219In the pursuit of a sustainable healthcare system local government must not be left behind, write Michael Boyd and Judith Barnes.

Integration

The vision for the country’s health and social care services was articulated in the "NHS Five-Year Forward View"

Local government is a necessary player in implementing its aims, one of which was greater integration between health and social care. The spending review in November 2015 went further and included a commitment to full integration by 2020 – and local government has a key role in making it happen.

Integration means different things to different people, particularly in a world where people in health and local government do not speak the same language. Yet although integration was mentioned 17 times in the NHS Five Year Forward View it is not defined there or in the 16/17 planning guidance. Bizarrely, the 2020 goal refers to "significant improvements in performance metrics within the new CCG assessment Framework". There are none, and indeed no mention of integration - nor social care.

Integration is therefore key – but what does integration of health and social care mean and what forms can it take, particularly following the new powers to devolve public functions in the Cities and Local Government Devolution Act 2016? Monitor did comment on the range of meanings in its statutory guidance to CCGs on commissioning but at the level of provision: "Care and support is integrated when it is person-centred and co-ordinated".

Integration potentially covers all levels from planning to delivery and some involvement from consultation at one end of the spectrum, aligning outcomes and processes through to full engagement with joint or devolved decision-making and integrated provision of services.

Along with the NHS and other organisations responsible for health and well-being, authorities are being asked to help improve the health of the populations they serve. Collaboration across health and social care through adopting a more place-based approach is seen as the best opportunity to tackle mounting financial and service pressures.

Hopes for integrating and transforming health and social care are now pinned on Sustainability and Transformation Plans (‘STPs’) – but local authorities have complained they have not been fully included in the planning process, and that genuine community engagement is suffering while they try to catch up. There are also concerns that the focus of the STPs in some places is on ensuring sustainability of local NHS organisations.    

Integration – now a legal requirement

Integration is not new. Section 31 Health Act 1999 (now Section 75 of the NHS Act 2006) gave local authorities and NHS bodies the powers to enter into arrangements to exercise each others' functions through delegation or exercise them jointly with pooled budgets, allowing partnerships, joint commissioning and contracting – so long as the arrangements were likely to lead to improvements in provision/outcomes.

Health and Wellbeing Boards (‘HWBs’) were created by the Health and Social Care Act 2012 along with the transfer of Public Health to local government and the introduction of duties for local authorities to promote the health and wellbeing of the local population.

A new duty for local authorities and partner CCGs to produce a Health and Wellbeing Strategy (addressing concerns identified in the Joint Strategic Needs Assessment, required under section 116 Local Government and Public Involvement in Health Act 2007) was introduced and new duties imposed on them to have regard to the strategies in all of their decision-making (section 116B 2007 Act – likewise the NHS Commissioning Board). 

Interestingly, in preparing a strategy under section 116A, the local authorities and partner CCGs are required "to consider the extent to which the needs could be met more effectively by the making of arrangements under section 75 of the National Health Service Act 2006 (rather than in any other way)".

HWBs were given broad obligations including:

"… for the purpose of advancing the health and wellbeing of the people in its area, encourage persons who arrange for the provision of any health or social care services in that area to work in an integrated manner".

The 2012 Act also required that “a relevant clinical commissioning group must co-operate with the Health and Wellbeing Board in the exercise of the functions of the Board", and that both NHS England and each CCG "must exercise its functions  with a view to securing  that the provision of health services is integrated with the provision of health related services or social care services”, but only where there are benefits in terms of quality accessibility or improving equality of outcomes to the health services. Later, the 2014 Care Act placed further integration, co-operation and partnership requirements on local authorities and agencies involved in care.

This year, the Cities and Local Government Devolution Act has proved one of the most significant pieces of local government legislation for a generation – allowing devolution whereby the Greater Manchester Combined Authority will jointly control the £6bn NHS budget alongside health and social care, likewise in Cornwall.

What is emerging is more organisations working more closely together to provide services and information that underpin well-being and deliver more people-centred services. This takes many forms including:

  • Shared management of functions;
  • Shared provision of functions;
  • Alignment of functions and funds;
  • Delegation of functions from one body to another;
  • Secondment of staff under section 113 Local Government Act 1972 into shared teams;
  • Joint health and social care commissioning and procurement strategies;
  • Alliance contracting;
  • Pooled funds;
  • Corporate or contractual joint ventures;

Or a mixture of the above.

STPs

Sustainability and Transformation Plans (‘STPs’) are the latest manifestation of the drive towards greater integration. The requirement for an STP was set out in the NHS Planning Guidance of December 2015. Although CCGs were still required to produce individual operational plans (something that they have been required to do since their inception), the December 2015 Guidance also required every health and care system to produce an STP. This document, to cover a five-year period, needs to demonstrate how local services would evolve, become sustainable and deliver the vision of the Five-Year Forward View.

Right now, in 44 areas across the country, STPs are being drawn up in support of the ‘Five-Year Forward View’ vision. The aim is to switch the focus from organisations to place-based systems - and so encourage services to work collectively to improve the quality of care and the well-being of the populations they serve.

The clock is ticking, since all STPs have to be submitted by the end of June. All stakeholders with statutory responsibility for health and well-being need to be onboard.

The Government's objective, is to harness the efforts of all those involved in the commissioning and provision of health and care on a local basis to address the three health-related goals of better health, transformed quality of care and sustainable finances:

  • The health and wellbeing gap: plans for a radical upgrade in prevention, patient activation choice and control and community engagement. In particular, this would cover preventable diseases, the reduction of demand for health services, obesity, diabetes, self-care and reducing health inequalities.
  • The care and quality gap: plans to develop new models of care and how digital technology could be used to improve outcomes and efficiency. This is the heading under which plans to develop Vanguards and new models of care would be detailed.
  • The finance and efficiency gap: plans to restore the finances of the NHS across the footprint and to deliver efficiency.

STPs of sufficient quality will qualify for access to the Sustainability and Transformation Fund ("STF") to help them to deliver their plans. In 2016/17, the STF stood at £2.139bn of which £1.8bn has been earmarked to bring the NHS provider sector back into financial balance. The STF will grow to £2.9bn in 2017/18, rising to £3.4bn in 2020/21, with an increasing share of the growing fund being deployed on transformation.

It is a huge undertaking, and there are concerns that in the rush to get things done, local government may have been left behind. Recently, the Local Government Association (‘LGA’) wrote to the Health Secretary to complain about the pace of implementation and a ‘lack of consideration’ – with locally elected leaders not being given a proper opportunity to ‘engage in the process’.

NHS England has made it clear that local government involvement is not only a requirement but also fundamental in developing a high quality STP.

However, given that not all STPs will reach the required standard (and will fail to attract STF as a result) the fear is that a two-speed NHS will emerge where health economies with supported STPs continue along a path to improved care, but leave others facing serious consequences.

The role of local government

Perhaps one factor discouraging local government involvement is a perceived lack of confidence in the ability of HWBs to deliver change and encourage health commissioners to act in a more-joined up way. By contrast, local government is wary of NHS England’s top-down approach to planning, exemplified in the Better Care Fund schemes.

There is also a sense that after the abolition of the strategic health authorities, nobody is in charge of delivering integrated health systems and organisational support (for example the separation of the community estate for the planning process is also a risk flowing from the separate roles of NHS property Services Ltd and Community Health Partnerships Ltd).

STPs have the potential to fill this void through a place-based approach – and local government has the edge in delivering the integrated systems that are now being demanded. In several areas, over a number of years, there are case studies where health, social care, housing and community partners have forged successful relationships.

Local government can boast an impressive track record in persuading organisations to give up some of their independence to join networks where resources are pooled in the interests of places and communities.

Lessons from the Vanguards and the Better Care Fund should be shared. Local authorities should also focus on how they can support the NHS aim of seven day working by helping to prevent people seeking emergency admissions and/or assisting them to be supported in the community as soon as possible following admission to hospital. There are key roles for local authorities in improving mental health and dementia services as well as care for those with learning disabilities. STPs also need to be flexible enough to fit with devolution this develops over time and assumes more responsibility for health and social care in some areas.

Local authorities must now ensure that detailed knowledge of community needs held by HWBs is factored into the STP process. This could happen in a number of ways through formal joint meetings of HWBs through to pooled teams of officers representing each footprint and of course in a number of areas through the new combined authorities that will deliver the devolution deals.

Local authorities are essential to the emergence of a sustainable healthcare system. The pressing issue now is to secure a seat at the table and meaningful input to the STP.

Governance

Critical will be putting in place the right governance arrangements that can involve the public and patients in contributing to that shared decision-making alongside public service leaders and private sector partners.

Each STP will be unique in its structure, and may involve networks or federations – or more formal alliances or mergers – which go beyond the partnership boards which have traditionally overseen operations in the health and care sectors.

Whatever models are chosen, they will need to pass some tough legal thresholds and have greater rigour around leadership, decision-making and conflict resolution. Some arrangements may require joint ventures or introduce commercial and corporate funding arrangements into the provision of public services.

As the King’s Fund suggests, the over-arching governance principles will need to be around system leadership and collaboration, rather than structures that are focused on organisations.

Criteria for success

It is clear that local government involvement is fundamental in developing a high quality STP, and could be the key to unlocking some of the problems faced by the NHS in delivering patient centred health and social care.

For some, STPs are the main hope in providing a sustainable NHS for the future. The transformation required from an organisation-based service to a structure that instead collaborates with local authorities and other partners and focuses on local populations is enormous.

It would be a shame if this vital work gets drowned out – by parallel negotiations on contracts for 2016/17 between commissioners and providers.

Tactically, it is clear that what is required is a document which is based on strong analysis and detailed insight into the issues faced within local health system. As such, great care will need to be taken to ensure that there has been a complete review taking all opinions into account, not only in relation to the underlying problems but also the range of potential solutions identified to address them.

Glossy brochures simply won’t do. As the NHS guidance on STPs stated:

"The best plans will have a clear and powerful vision across health, quality and finance, owned by all local partners in the system. They will create coherence across different elements, for example a prevention plan; self-care and patient empowerment; workforce; digital; new models of care; trusts in special measures and finance. They will systematically borrow good practice from other geographies and adopt national frameworks."

Successful STPs will also need to address the huge role that good quality housing has in supporting health and well-being. In an era of closer collaboration between sectors, housing providers should be regarded as obvious partners to help deliver improved health, as has been recognised recently by the Healthy Towns Initiative.

With the deadline fast approaching at the end of June, the scale of the task is daunting. It will be vital for these plans to provide a solid foundation on which to build integrated systems of care that will be essential to future public health and social care.

After the controversy over the top-down Lansley reforms, there is a clear and genuine attempt to involve all key stakeholders in helping to shape the new health and care system. It is vital that, having issued this call to action, everyone with a voice not only responds but is a welcome participant.

Michael Boyd and Judith Barnes are partners at Bevan Brittan LLP. Michael can be contacted on 0370 194 5470 or This email address is being protected from spambots. You need JavaScript enabled to view it., while Judith can be reached on or This email address is being protected from spambots. You need JavaScript enabled to view it..