The current financial environment in the NHS and local government is ‘hindering progress’ on place-based integration and ‘actively undoing it’ in some areas, according to an NHS Confederation report.
The report published today, called The State of Integration at Place, suggested this was a ‘clear message’ after interviewing 60 participants across 25 integrated care systems (ICSs).
It said: ‘The current financial environment in both the NHS and local government is not only restricting place integration in some areas but, in many cases, actively undoing it because:
‘1) a national emphasis on getting a stronger grip on the financial pressures in the NHS has led to command-and control behaviours trickling down into the system; and 2) the running cost allowance reductions asked of integrated care boards (ICBs) have had a restricting effect on affected place-level teams.’
Local leaders in some systems noted they could not progress towards the vision of place-based integration until their financial position improved, and that this had an impact on local relationships.
‘This issue stems from local leaders’ lack of capacity to respond to needs beyond immediate needs, let alone undertaking transformational changes in how health and social care is planned, organised and delivered, but also due to behaviours around accountability and performance management that trickle down from a national level and, in the words of interviewees, “incentivise counterproductive behaviours locally”,’ said the report.
Interviewees suggested place leaders should set their own outcome targets supported by ‘light touch’ national guidelines.
The report said: ‘This is not currently the case, but is particularly crucial to shifting towards a preventative, community-first model of care.’
It added: ‘ICBs have needed to respond to significant reductions in their running costs, which is affecting progress towards integration at place. Some systems have straightforward staff reductions of 20-30 per cent reductions across all directorates, maintaining existing models but with downsized teams.
‘Others have used these reductions as an opportunity to rethink their operating models as a whole and consider whether there is a more transformational shift they want to make.
‘Regardless of the outcome of those processes, interviewees were clear that it has had a big impact on progress towards integration and delivery at place.’
The report suggested that place is the scale at which system integration is ‘best delivered’ and that leaders were keen to see place given more prominence in national policy and budgets.
It made several recommendations to support the acceleration of integration at place, including for system leaders to support place leaders to set out realistic timeframes for the evolution of their partnerships.
NHS and local government should work together as ‘peers’, according to the report, in order to empower place and ensure the devolution agenda was aligned and complementary across both sectors.
It also made recommendations for national government, including that integration at neighbourhood and place level should be at the heart of the 10-year plan and that funding should align with this (see box for full recommendations).
The report follows calls from NHS chief executive Amanda Pritchard for secondary care providers to fix the working relationship between them and primary care, and not rely on the latter to do so.
Last month, Ms Pritchard said the 10-year plan would need NHS fingerprints ‘all over it’, as the Government launched a consultation to inform the document.
Report’s recommendations for national government
- Integration at neighbourhood and place should be at the heart of the Department for Health and Social Care’s ten-year reform plan for health, expected in spring 2025. It should state clearly that this is crucial to achieving the government’s ambitions to create a community first, neighbourhood health service, delivering more preventative, proactive care, economic growth, as well as meeting the short-term challenges facing public services. This should also apply to all future health-related integration policy.
- The shift to a community-first approach should be recognised as one of the biggest change programmes in the sector’s history and supported as such.
- National leadership should communicate clearly with the sector to acknowledge that this change requires accepting that greater risk and disruption may be necessary.
- The plan should consider how regulatory approaches and performance management can adapt to better enable and encourage collaborative work and innovation focused on preventative, proactive care.
- The government should consider a refreshed Total Place policy programme, assessing how the public pound is spent at place, where people live their lives. This has potential to increase efficiency in line with the government’s economic growth agenda, reducing duplication in local delivery, and improve outcomes for local populations by focusing on what works locally.
- HM Treasury, DHSC and NHS England should shift the NHS onto multi-year funding and planning cycles, and align these with local authorities, to enable long-term planning and accelerate integration in budget management, planning and delivery between health and local government.
- DHSC and the Ministry of Housing, Communities and Local Government (MHCLG) should together review Better Care Fund and Section 75 arrangements and consider how they can make pooling budgets easier, including by reducing the reporting and governance requirements associated with them.
- DHSC and NHS England should implement the Hewitt review’s recommendations related to how non-recurrent funding is managed, with fewer stipulations on how it is used locally, and reducing the number of national targets, focusing more on outcomes than activity.
- They should also be reviewed to consider how they can best deliver the government’s ambition to create a community-first, neighbourhood health service (that is, by incentivising the change described under recommendation 1).
- DHSC, MHCLG, NHS England, the LGA and NHS Confederation should work together to influence cross-Whitehall policymaking to ensure place is recognised as a crucial delivery mechanism on all issues that relate to health and social care and to normalise this language and way of working through policy.
