As the Health and Care Bill continues its passage through Parliament, the government has published an integration white paper that does little to clarify how its flagship integrated care system reforms will work. Fortunately, there’s more clarity about their immediate tech agenda. Highland Marketing explains.

Here’s some bad news for anybody looking for a nice, simple explanation of how to engage with an integrated care system and what it is trying to do.

Even though the Health and Care Bill that is supposed to put ICSs on a statutory footing is still working its way through Parliament, the government has just issued an integration white paper that adds new layers of complexity.

In fact, it often reads like a paper looking to reform the system that hasn’t even been set up yet. For example, ‘Joining up care for people, places and populations’ wants a single person to be responsible for planning and commissioning both health and social care at local level.

To achieve this, it says a third board will be added to the two boards that ICS areas are setting up on the ground. It also wants to make sure that ICSs are aligned with national policy and “accountable” for delivery.

To achieve this, it shifts the attention of ICSs away from the big concepts of joined-up care and population health management that form the spine of the Bill and its preceding plans and towards a new outcomes framework with “transparent” targets.

If there’s better news for health tech vendors, it is that the paper is on board with a lot of the ideas in the health and social care data strategy and the ‘what good looks like’, and ‘who pays for what’ papers. Although there are hints that it wants social care IT to be locked into the NHS orbit. Some key points:

Why has another white paper been issued?

When the government finally published its social care white paper in December, it also promised an integration white paper.

The Health Service Journal reported that this was because Number 10 wanted a “single person accountable for health and care services in a local area”; which is not the model set out in the Health and Care Bill or the ‘integration and innovation’ white paper that preceded it.

Chunks of ‘integration and innovation’ were written by NHS England, with additions from former health and social care secretary Matt Hancock. But the new white paper is a joint production by the Department of Health and Social Care and the Department for Levelling Up, Housing and Communities, led by their new ministers Sajid Javid and Michael Gove.

In a joint foreword, they set out some big ambitions for what they describe as “the beginning, not the end, of a new wave of reform.” In the order in which they appear, these start with a stronger focus on citizen and patient empowerment.

After which, they get into: joining-up health and social care; “giving health and social care professionals the right data and technology to make more informed decisions”; creating a “more agile workforce with care workers and nurses moving easily between roles in the NHS and the care sector”; levelling up health outcomes; and “championing health and well-being” with a “stronger focus on prevention”.  

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What does it mean for ICS structures?

Integrated care systems already have a complex structure, thanks to their long gestation. When it became obvious that legislation would be needed to consolidate the reforms set out in the NHS Long Term Plan, NHS England came up with an options paper that set out two models for ICSs.

In one model, they would have taken on the commissioning functions of clinical commissioning groups, but used them to drive whole system working rather than contracting. And in the other, they would have joined forces with local authorities to bring social care into the mix.

In the event, the government adopted both models in the Health and Care Bill (while adding a few powers for ministers to intervene on sensitive issues, like local reconfigurations). So, NHS England has told ICSs to create two boards; an integrated care board or ICB to run local health services; and an integrated care partnership or ICP to work with councils and other stakeholders.

To deliver Number 10’s vision of a single person responsible for health and social care planning at a local level, ‘Joining up care’ adds a third board; an integrated health and social care board at ‘place’ level. It says this ‘place board’ should have a lead or ‘single accountable person’ or SAP responsible for delivering agreed outcomes.

It also says ICBs and ICPs will be “expected” to delegate authority and budgets to place level so this can happen. However, as commentators have been quick to point out, the Health and Care Bill doesn’t mention these new boards and gives them no statutory authority to do anything.

Despite this, the paper is likely to trigger some further boundary changes on the ground, as ICSs accommodate ‘place’ boards and try to align them with local authority boundaries. There are 42 ICSs and its likely that there will be around 150 ‘place boards’.

What does the new white paper think ICSs will be doing?

Drawing on the NHS Long Term Plan, the ‘integration and innovation’ white paper, and the Health and Care Bill, NHS England published a design framework for integrated care systems. This says they should set themselves up to deliver four core aims.

These are: to improve both population and health outcomes (using a population health management approach); to tackle inequalities; to enhance productivity and value for money (for example by joining up services and developing data driven pathways); and to “help the NHS to support social and economic development”.

‘Joining up care’ doesn’t disagree with or ditch any of these aims – at different points, it says it wants all of them. However, when it comes to discussing what local NHS and local authority leaders will be expected to do, it shifts focus to making them “accountable” for delivering against “agreed outcomes”.

Specifically, it talks about creating a new outcomes framework that will simultaneously reflect national policy and deliver for communities and people. For old hands, this sounds a lot like one of the ideas behind Andrew Lansley’s reforms of the NHS in 2012 (which the Bill is otherwise trying to unpick).

Lansley wanted the Department of Health to hand a mandate to the NHS commissioning board, which would then be responsible for setting up the commissioning system to deliver those outcomes, and for monitoring progress.

In another loop-back to the policy obsessions of the mid-2010s, the white paper also revives Lansley’s “transparency” agenda by suggesting that performance statistics could be published, so people can see how their areas are getting along.

Is there a role for digital and data?

Matt Hancock’s digital agency, NHSX, did a fair bit of work on technology for integrated care systems before it was absorbed into NHS England’s new transformation directorate. It published a data strategy for health and social care and papers on ‘what good looks like’ and ‘who pays for what’ to support the ICS design framework.

In a bit of good news for the suppliers already engaged in this space, the integration white paper largely adopts this work and sets out to build on the requirement for all ICS areas to have a ‘basic’ shared care record in place by September 2021 and a ‘comprehensive’ shared care record in place by March 2024.

However, the paper pushes this approach at some points. For example, it appears to suggest that a ‘comprehensive’ shared care record should include “safe access” for citizens and care givers as well as health and care professionals, and that individuals should be able to contribute to it.

The white paper also reiterates the design guidance instruction for ICSs to develop “digital investment plans for bringing all organisations to the same level of digital maturity” and for “allowing data to flow seamlessly across care settings.

But it puts a stronger focus on having “real time” data available at place level that will support “proactive care” and that “mandatory reporting” of outcomes. The paper says that an updated and final data strategy will be along this year, to flesh out the detail.

What about technology for social care?

Through the Covid-19 pandemic, NHSX and NHS Digital had a big push on getting care homes and care providers onto NHSmail, on getting them through the DTAC so they could use more NHS services, and on rolling out electronic care records in a sector that is only 40% digitised.

The integration white paper continues this direction of travel, which the social care white paper promised to fund to the tune of £150 million over the next three years. However, there is a strong focus on integrating health and social care systems that is being driven from the health side.

The white paper says that care suppliers will be expected to use the NHS Number as their primary identifier, that any newly digitised provider should be hooked up to its local shared care record within six months of go-live, and that there will be a “suite of standards” to support information exchange, starting with streamlined terminology standards this year.

The white paper also envisages staff moving more fluidly between health and social care, which is likely to trigger new technology requirements, to enable them to use familiar systems in new settings. The paper recognises there will be a need for better digital skills across the piece, and outlines a number of new schemes, including a “comprehensive learning offer” for social care staff.

Predictably, the white paper also wants to put more technology into the hands of individuals, carers and patients, and mentions developments for nhs.uk, the NHS App, acoustic monitoring for falls in care homes, a big roll-out for virtual wards, other remote monitoring developments, and patient apps.

Virtual wards are likely to come first. The NHS operational priorities and planning guidance that came out in January said ICSs should be looking to set up 40 or 50 bed virtual wards to reduce pressure on acute facilities.

Reaction

The new white paper has received a mixed reception. Readers on the Health Service Journal’s initial story were in despair at the new layers of complexity added to integrated care system arrangements; which, they pointed out, run the risk of replicating the structure and functions of clinical commissioning groups.

However, Dave West, the magazine’s resident ICS expert, is kinder in an analysis piece. He argues the white paper is “a little scrappy” because it is trying to square the “impossible policy circle of trying to clear up accountability, without actually changing anything.”

But if it’s read as an attempt to “give the NHS a general shove I the right direction” it’s probably “pretty sensible.” In this spirit, the NHS Confederation also said that while the white paper “could be considered a green paper as there are several areas that will require further exploration and clarification” it can be “broadly welcomed” as “largely reinforcing existing policy.”

The problem, West points out, is that a “shove in the right direction” is needed because the Health and Care Bill barely talks about place. The government is not about to pull it apart and start all over again so, as the NHS Confederation also points out, the poor SAP supposedly responsible for planning and outcomes at place level will have no formal strings to pull.

Nigel Edwards of the Nuffield Trust identifies another problem, which is that while attention has been focused on ICSs, some large acute trusts have been quietly forming up into “hugely powerful provider collaboratives” that will be able to call the shots whatever their planners and commissioners say.

In random articles in the press, health secretary Sajid Javid has effectively backed this provider agenda, with his talk of ‘academy trusts’ and hospitals running GP practices. Whatever the pros and cons of these ideas, they run counter to the ideas in both the Health and Care Bill and the new white paper.

While this sounds (and is) arcane, the reason it’s bad news for anyone trying to get a handle on what is going on is that it remains entirely unclear what the final form of ICSs will be, where power will lie.

Meanwhile, West argues that the white paper is useful because it suggests a simplified task for ICSs, which is to focus on whatever reduced set of priorities go into the outcomes framework. In the long-term, this should help health tech vendors who want to build systems and products to support the new regime, by putting more clarity and structure around what is required.

However, the publication of any framework is a long way off. Fortunately, there’s plenty for shared care record, remote monitoring, social care and app vendors to be getting along with in the meantime. Which has to be a good thing since, given the state of the present government, it might never happen.

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