Dr Sarah Clarke, RCP clinical vice president, sets out the RCP’s priorities in the government’s proposals for a new health and care bill.
Last month the government published its white paper Working together to improve health and social care for all, setting out legislative proposals for a new Health and Care Bill.
This is the next step in getting legislative changes that the NHS Long Term Plan said were needed to speed up the integration of services, and so many of the proposals have come from the recommendations that the NHS itself made to parliament in 2019. As I said in my previous blog, while our consultation with members showed understandable nervousness about another 2012-style ‘top-down reorganisation’, there is a lot to be positive about in these legislative proposals and the RCP supports the direction of travel.
What is the purpose of the white paper proposals?
It is all about integrating health and care – it recognises that neither the health system nor local authorities can meet the health needs of their populations alone. It seeks to embed joint working by making integrated care systems (ICSs) statutory, and both the NHS and local authorities will be given a duty to collaborate with each other, which will replace existing collaboration duties.
The proposals are centred in a population health approach and government hopes that by removing legislative barriers, the scene will be set for different parts of the system to come together and take bold, collaborative action to serve that population. We agree with this: as we have said, integration will not happen without teams working differently, and we encourage physicians to be a part of this.
New structures – legislating for integrated care systems
ICSs will be put on statutory footing, made up of an ICS health and care partnership and an ICS NHS body. The partnership will bring together the NHS, local government and other local partners to develop a plan for the health, public health and social care needs of its population, while the NHS body will be responsible for the operational day-to-day running of the ICS. Both bodies must draw on the expertise of NHS and social care staff and support hyper-localised ‘place-based’ working between health, local government and other partners in the voluntary, community and social enterprise (VCSE) sector.
There will be a ‘triple aim’ duty on health bodies, including ICSs, which means they must pursue better health and wellbeing, better quality of health services, and sustainable use of NHS resources. A capital spending limit will be imposed on NHS foundation trusts. The RCP supports ICSs being put on statutory footing, but we want to see more detail on how the relationship between the NHS ICS body and the health and care partnership will work in practice to ensure all stakeholders are meaningfully involved.
A big theme is the reduction of bureaucracy following the Department of Health and Social Care’s ‘bureaucracy busting’ review. One element of this that might be of particular interest to physicians is that the existing legal requirement for all assessments to take place prior to discharge will be replaced with a ‘discharge to assess’ model where continuing healthcare, funded nursing care and care act assessments will take place after discharge.
Collaboration over competition, and new powers for the secretary of state
One welcome change is the competition role of the Competition and Markets Authority being repealed. Commissioners will be given more flexibility in arranging services through a new bespoke health services provider selection regime, reinforced by further reforms to the tariff.
The white paper also gives the secretary of state for health and social care new powers. NHS England and NHS Improvement will be formally merged and put on a statutory footing as ‘NHS England’; and the secretary of state will have new ‘appropriate intervention powers’ to direct functions of the newly merged body. This includes specific public health functions, and the white paper promises that further restrictions on the advertising of high fat, salt and sugar foods will be introduced as well as food labelling requirements. The secretary of state will be able to intervene in local service reconfigurations such as a hospital closure and be able to create new trusts.
Another power will be given to the secretary of state to transfer the functions of bodies – although the white paper says there are no plans to use this in the immediate term except for the creation of the National Institute for Health Protection (NIHP) and the resulting reallocation of responsibilities currently held by Public Health England (PHE). The annual NHS mandate will also be replaced by a more flexible rolling one, and the better care fund will be separated from the mandate.
Greater government accountability for workforce
On workforce, the secretary of state will have a new duty to publish a report once a parliament to ‘support greater clarity around workforce planning responsibilities’. In our original submission on these proposals in 2019 we called for a duty on the secretary of state for workforce planning – we now want to know what will be included in this report, where the data that informs it will come from and whether it will make recommendations.
While improved transparency on responsibilities is welcome, we want to see greater accountability in the system. It is welcome that this report will be co-produced at a minimum with Health Education England and NHSE, but any projection data held by those bodies on workforce needs to be put into the public domain so they can be critiqued. We want to see a designated body have clear responsibility for publishing workforce projections and for the secretary of state to have a duty to respond to those projections with a plan for what government will do to ensure the NHS has the workforce it needs.
Other proposals on workforce include local education training boards being removed from statute and new measures to improve the current regulatory landscape for healthcare professionals as needed.
The missing pieces – social care and public health
While there are lots of things to be positive about, the notable absence of detail on key areas such as social care and public health makes it harder to visualise and assess the future system in its entirety. There are some new proposals on social care, such as a new assurance framework for local authority-delivered care and improved data collection, but generally the white paper delays most of the detail for the government’s reform plans which are expected later this year. Proposals for the future of public health are also promised ‘in due course’.
Giving an ICS responsibility for population health is likely to lead to greater investment and focus on preventative measures, but this needs to be complemented by increased funding for public health. It is disappointing to see that the Budget did not bring any specific funding for this after the Spending Review in 2020 also failed to deliver much-needed investment to a sector that has been so key to the pandemic response. We need to see fuller proposals on both NIHP and social care before the legislation comes to parliament so we can assess how all parts of the future system will fit together.
Tackling health inequalities must go together with integration
The pandemic has exposed the health inequalities that ran deep in our society before COVID-19 hit and it is welcome that the white paper acknowledges this. The government’s own research states that ‘a range of socioeconomic and geographical factors such as occupational exposure, population density, household composition and pre-existing health conditions’ are behind the different mortality rates among ethnic groups. We said in our initial consultation response that legislative change would need to be underpinned by measures to address these inequalities and this is still relevant. Without tackling the overarching determinants of health at national policy level, an ICS’s best efforts to prevent ill health locally can only go so far.
Since 2019 we have been speaking to members and stakeholders and will continue to do so. The proposals outlined in this paper are expected to come into force in 2022; we now wait for the publication of legislation to understand how many of these ideas will work in practice. If you have any concerns or questions, please let us know at email@example.com.