UK Government plans to more closely integrate health and social care in England will not succeed in their aims to improve care quality, personalisation and value for money without adequate funding and staffing, sector bodies have warned.
The integration white paper, issued yesterday, includes plans to make a single leader accountable for delivery against joint health and social care outcomes in each area, make pooling budgets easier, create shared care records for individuals and remove barriers to staff moving between the two workforces.
The government said it would tackle a situation in which “too often patients find themselves having to navigate complex and disjointed systems”, people with multiple conditions have to explain their stories to multiple professionals and others face delayed discharges because the NHS and councils are working to different priorities.
However, while sector bodies welcomed the white paper’s ambitions and the government’s relative lack of prescription on how local areas should integrate, they warned they would not succeed without tackling significant funding and staffing shortfalls, which have deepened in social care over the past year.
“The overall emphasis on promoting closer integration of health and care services is welcome – and fits with what the NHS and local authorities are already trying to do in different parts of the country,” said Hugh Alderwick, head of policy at health and social care think-tank the Health Foundation.
More integration ‘little good without enough staff’
But he added: “Better integration between services is no replacement for properly funding them. The social care system in England is on its knees and central government funding over the coming years is barely enough to meet growing demand for care – let alone expand and improve the system.
“More integration is also little good if there aren’t enough staff to deliver services. Staffing shortages in health and social care are chronic, yet government has no long-term plan to address them.”
His concerns were echoed by Nigel Edwards, chief executive of fellow think-tank the Nuffield Foundation.
“There is a risk that the white paper overestimates the extent to which structural changes will produce the results expected. We also need to see workforce and funding issues addressed and allow the time and space to build the strong partnerships and cohesive culture where better results for patients can be delivered. The need for investing in better relationships with councils comes alongside the huge pressure NHS leaders remain under to cut waiting times and provide more care.”
Edwards said the foundation’s analysis of past attempts at integration showed that “it alone does not deliver financial savings, bolster social care or reduce hospitalisations as much as the government would hope”.
Integration white paper: key proposals
- Shared outcomes: local NHS and council leaders in England will be working to shared health and social care outcomes by April 2023, some set nationally and others locally. This should not add to existing burdens so the government will consider how these can be aligned to existing outcome frameworks. It is likely that the Care Quality Commission will assess councils against these outcomes when performance assessments of adult social services are reintroduced, in April 2023 at the earliest.
- Accountability: all local areas should have a system of accountability, which the government expects will include a shared, resourced plan for delivering against shared outcomes, encompassing a significant proportion of health and social care activity, by spring 2023.
- Single leader: there should be a single person who is accountable for delivery against the shared outcomes and plan, agreed by the relevant local authority or authorities and integrated care board (the new NHS structures that will replace clinical commissioning groups, but covering much larger areas, later this year). This will not change existing accountabilities for local authority or NHS leaders.
- Pooled budgets: the government will review existing legislation governing pooled health and social care budgets – under section 75 of the NHS Act 2006 – and publish revised guidance, to make the process simpler.
- Shared care records: by 2024, each integrated care system should have set up shared health and social care records for all citizens, and be working towards giving people, their caregivers and professionals access and the ability to contribute to them.
- Workforce: the government plans to make it easier for staff to move between health and social care, including through testing joint roles, considering the introduction of an integrated skills passport, to transfer skills between the NHS, social care and public health and exploring developing a framework for clinical staff to delegate interventions to adult social care workers.
The Local Government Association said it welcomed the “ambition” of the white paper “ambition for joining up health and care services to get better outcomes for individuals and communities”.
Adult social care ‘in fragile position’
However, community wellbeing board chair David Fothergill warned: “Adult social care is in a fragile position, with councils struggling to balance budgets and services severely impacted by rising costs and recruitment issues. A long-term funding solution is urgently needed in order to ensure a sustainable, high quality and sufficient care and health workforce to meet needs now and going forward.”
The government has set out plans to reform the funding of adult social care – by setting an £86,000 cap on personal care costs and making the existing means-tested system more generous to people with moderate wealth – while also investing in workforce development and wellbeing, at a cost of £5.4bn from 2022-25. In addition, councils will receive an extra £1bn to spend on children’s and adult social care in 2022-23 through the local government funding settlement, finalised this week.
But the LGA said that the money was insufficient to tackle current social care pressures or provide room for investment in early help and prevention.
The County Councils Network gave a relatively positive response to the integration white paper, describing it as “another important step on the integration journey that county authorities and their health partners have been on for a number of years”. However, adult social care spokesperson Martin Tett stressed that “further funding [would] be needed to maximise the success of these proposals”.
There was a similar message from the Social Care Institute for Excellence, whose chief executive, Kathryn Smith, said: “The government’s white paper for the integration of health and social care is the right way forward, but realising the ambition requires long-term commitment and investment. Integration will not resolve the urgent issues of stabilising the social care system or tackling the backlog of NHS demand.
Meanwhile, Saffron Cordery, deputy chief executive of NHS Providers, which represents trusts, said: “Pooling NHS and social care budgets is no substitute for funding both systems appropriately and placing social care services on a sustainable footing.”
Lack of workforce plan
Social care workforce development body Skills for Care welcomed the white paper but highlighted the absence of a plan for the social care workforce.
“Integrated care is about people having to tell their story once and is reliant on relationships and trust, with providers of care and health working together irrespective of uniform or badge,” said chief executive Oonagh Smyth. “This will only be achieved if we are able to attract and retain staff with the right mix of skills, and a properly recognised and rewarded adult social care workforce will be vital in making sure that happens.
“Creating a national plan for our growing social care workforce will be critical as we consider what a fully funded integrated care system looks like, and whilst the integration white paper has a welcome recognition of the importance of placed based workforce planning there was no mention of a national workforce plan.”
From an NHS perspective, Cordery added: “Local partners across health and social care are making steps to better integrate health and care teams but they will need to be supported with much better national planning and information on workforce needs to make this a reality across the piste.
Single leader ‘should be from local government’
She also raised concerns about the plan for a single leader to have accountability for shared outcomes across local areas, adding that it “could further complicate lines of responsibility in already complex, developing system working structures”.
For the County Councils Network, Tett said that the leader should come from local government.
“With county authorities offering the scale as place leaders in bringing together key public sector partners, it is critical that an individual from local government should be the ‘single accountable person’ to lead on integrated care partnerships,” he added.
The white paper said that its proposals for integration were based on “places”, which it defined as having populations of 250,000 to 500,000, “for example at borough or county level”. However, it was not clear on what the boundaries of places would be.
Both the LGA and the CCN stressed that they should be based on council boundaries.
For the LGA, Fothergill said: “The LGA has long argued for a strong role for place-based leadership of care and health. We believe that integrated care systems should develop their place-based arrangements on existing local authority boundaries since many of the components of joined up working already exist at this level.”
Tett added that county councils should “be the ones who lead on devising the most effective local structures to focus on improving community care options and tackling the wider determinants of poor health, working alongside primary care partners”.