NAPC response to the Department of Health and Social Care White Paper Integration and Innovation: working together to improve health and social care for all

NAPC response to the Department of Health and Social Care White Paper Integration and Innovation: working together to improve health and social care for all

On 11 February 2021, the UK government formally published its white paper on NHS reform. The paper sets out reform changes in legislation proposals, with the aim to transform health and care systems across England.

The white paper proposals build on the recommendations made by NHS England and NHS Improvement in Integrating care: next steps to building strong and effective integrated care systems across England and can be categorised into the following themes: working together and supporting integration, reducing bureaucracy, enhancing public confidence and accountability and additional proposals to support public health, social care, quality and safety.

NAPC and the White Paper

In this paper, we go through the key proposals in the paper and describe how each theme relates to the NAPC mission to improve the health and wellbeing of defined populations locally, nationally, and internationally. We highlight the high-level opportunities and challenges in the proposals from a NAPC perspective, which favours a person-centred care approach and integrated working.

As a membership organisation, our membership consists of leaders and innovators in the field of service development who are keen to influence policy and shape the system around them for the benefit of their community. Therefore, it is vital we inform our members, primary healthcare colleagues and system partners on the areas where there are opportunities and room for challenge in the legislative proposals.

The intent of this paper then is to inform those individuals who share our same passion of joint working and patient-centred care on the possible outcomes the legislative proposals have and areas where members can influence as leaders.

The NAPC Journey and Learnings

Dedicated to population health improvement, we have observed successful integration being achieved with system partners working on the ground from 2015 with Sir Simon Stevens NHS England Chief Executive launching the NAPC primary are home model (PCH) – the original primary care network.

We have worked with more than 240 PCH sites (19% of PCNs) across England, covering 10 million patients. NAPC has worked and is working with 16 Sustainability Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) spreading the PCH/Primary Care Network (PCN) model to one fifth of the health and care system. The learnings from the PCH and the approach to their development that we pioneered were used by NHS England and Improvement in the design of PCNs (in the NHS Long Term Plan).

In our learnings, health and care systems that address the health and well-being needs of communities are invariably founded on one-to-one interactions between empowered people, families, and carers in partnership with proactive, prepared primary care teams. Understanding the health and well-being needs and health inequalities within communities at a neighbourhood level is critical to build the appropriate support and care needed at a local level.

Consolidating decision making at an ICS level in the absence of the understanding and mechanisms to support the local neighbourhood planning approach threatens to take us back 30 years and in the opposite direction of an NHS based on improved population health and greater integrated working.

A person-centred approach is only truly supported by a local approach that builds support and services from the needs of individuals and communities upwards to larger populations. Success needs to be defined, measured, and enabled around improved health and well-being of communities and reduced health inequality within those communities.

NAPC Membership

NAPC as a membership organisation recognise and support the acceleration towards fully Integrated Care Systems (ICSs) through legislative changes and that this brings about implications for change across primary healthcare and our members.  Our membership is led by serving health care professionals, which grounds them with practical experience and gives them real credibility as they work with across many providers, local government and primary health and care teams.

NAPC members share our dedication to improve population health and are well placed to contribute to proposals. Earlier this year, our members were keen to share their response on the consultation process. You can view their collective response here: napc.co.uk/napc-responds.

Through our transformation work leading to influencing national policy, we have been functioning across many systems to support long term plan development in particular the role of primary healthcare in system integration.

Please see below for the team’s comments on what the White Paper means for NAPC.­­

NAPC Executive Team comments

Dr Minesh Patel, NAPC Chair, comments:

NAPC has paved the way for a more integrated health and care system through the primary care home model. It’s all in the translation though from White Paper to delivery to the citizen’s front door”.

 

 

Dr Johnny Marshall, OBE President of NAPC, comments: 

There is unanimous support from NAPC’s Council & Members’ towards the notion of emphasising the need for and strength of empowered individuals and communities and recognition that we would be promoting this in an environment where the language talks the talk”.

 

Introduction

In this paper, we are keen to share with our members – leaders working in healthcare delivery – how the proposals in the White Paper impacts areas they are dedicated to improving and making an impact on.

The White Paper highlights key proposals for healthcare which are summarised below:

  • Integrated Care Systems (ICSs) becoming a statutory body with role of clinical commissioning being taken over from Clinical Commissioning Groups (CCG’s) accountable for running of the ICS, NHS planning and resource allocation.
  • Development of NHS ICS boards and NHS ICS Health and Partnership Boards bringing together local partners such local government, social care, and voluntary sector.
  • Development joint committees for governance across NHS ICS and NHS Providers
  • Establishing ‘a duty to collaborate’ across all partners of the local system.
  • New powers for the Secretary of State for Health and Social Care over the NHS in England including new service reconfigurations, create new Trusts such as seen with nightingale Hospitals, arm’s length bodies (ALB’s)
  • Changes to procurement and competition and the NHS having to put services out to competitive tender under a new system.

Proposal Changes

The proposed legislative changes are in the areas of working together and supporting integration, reducing bureaucracy, improving accountability, enhancing public confidence and additional proposals which include public health, social care, safety, and quality.

In the following sections we highlight each theme and the opportunities implications each proposal has.

 

Theme 1: Working together and supporting integration

1.1 What the White Paper states:

“At the heart of our legislative proposals, is the goal of joined up care for everyone in England. We propose to implement NHS England’s recommendations and legislate to support integration, both within the health service, and between the health service and local government, with its statutory responsibilities for public health and social care.”

Opportunities and implications:

  • Joined up health and care have to be good for citizens if this can be achieved. Systems need to work together, there are many of the mature ICS that are doing this already and it is important we learn from them and other communities in how we can achieve this.
  • Collaboration with communities to address inequalities using wider community assets is essential so that people and communities can play a role in planning supporting and influencing population health-based care.
  • It is essential we give equal place for all partners at the ICS table and ensure that primary healthcare has a strong voice in developing transformation plans and resources to build on work achieved already. This includes primary healthcare and local community and voluntary organisations who already have worked together successfully through the Covid 19 pandemic.

 

1.2 What the White Paper states:

We want to legislate for every part of England to be covered by an integrated care system (ICS) with a broad duty to collaborate. These bodies will be comprised of an ICS Health and Care Partnership, bringing together the NHS, local government and partners, and an ICS NHS Body. A key responsibility for these systems will be to support place-based joint working between the NHS, local government, community health services, and other partners such as the voluntary and community sector.”

Opportunities and implications:

  • Focussing on the requirements of people with similar needs is essential to support place based joint working across partners which is currently being implemented across may areas from which we can continue to learn form.
  • Create equality of voice within the ICS partnership – the governance arrangements should reflect this equality and include multi stakeholders from primary healthcare.
  • Build a better picture of community needs and community assets together. These relative needs and assets may be quite different across an ICS as might be the improvement journey.
  • Meaningful engagement with citizens – what matters to them – broad outcomes, personalised care.
  • PCICSs strategic plans are the building blocks to local planning and improving community health and wellbeing outcomes. They are not the finished product and time, and sustained support will be needed to develop a mature and effective approach to delivering on outcome.
  • Outcomes will be influenced by non-health factors, social, environmental, and behavioural if systems and partners start with understanding these issues bringing partners together across communities, we will have a great opportunity to create local solutions for our populations.

 

1.3 What the whiter paper states:

Triple aim duty on health bodies, including ICSs: “This will require health bodies, including ICSs, to ensure they pursue simultaneously the three aims of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.”

Opportunities and implications:

  • Build a consistent approach to developing multi-professional leadership to support population health focussed team-based care.
  • Create real cross system team working not ‘pseudo-teams’ (which are less safe than no team, evidence shows this has impact on people and teams working in healthcare – Michael A. West, 2012, ‘Real Teams or Pseudo Teams? The Changing Landscape Needs a Better Map’)
  • A collective value-based and patient-centred approach will ultimately be the only way to make best use of resources – it is what matters to people rather than what is the matter with people.
  • Focus on value-based care, reducing unwarranted variation, supporting shared decision-making, and support for self-care.
  • Investing in ‘non-health factors’ that influence 85% of people’s outcomes.

 

1.4 What the white paper states:

We will legislate to ensure more effective data sharing across the health and care system, which is critical to effective integration, and will enable the digital transformation of care pathways”.

Opportunities and implications:

  • Look at ways of understanding individual and community data that drives ill health.
  • Enable health and care organisations to test and innovate ‘tech first’ approaches to support people to manage their day-to-day care.
  • Working together across systems with data sharing and population health opportunities to inform ICS wide collaboration.

 

Theme 2: Reducing bureaucracy

2.1 What the white paper states:

We intend to reform the existing legislation to remove the barriers that prevent them from working together and to enable them to arrange services and provide joined up care in the interests of service users. This will require changes to both competition law as it was applied to the NHS in the Health and Social Care Act 2012 and the system of procurement applied to the NHS by that legislation. These changes will enable the NHS and local authorities to avoid needless bureaucracy in arranging healthcare services while retaining core duties to ensure quality and value.”

Opportunities and implications:

  • Consider value-enhancing partnerships with the commercial and 3rd sector to the benefit of the population – diagnostics, technology, self-support and remote care, digital infrastructure.
  • Removing bureaucracy in arranging healthcare across partners and procurement of services can only help transformation alignment of services.
  • Public confidence and accountability must be at the forefront of local service provision and reducing bureaucracy can play an important role with integration and alignment of services.

 

2.2 What the white paper states:

We wish to build greater flexibility where the current framework fails to enhance and streamline accountability. Covid-19 has presented a unique opportunity and imperative to drive real change in this area. When the pandemic struck, the NHS, the social care sector and partners were quick to cut through some of the bureaucracy that had accumulated over a number of years. Whilst some of these changes are only appropriate as part of an emergency response, others demonstrated how new ways of working could lead to better outcomes in more normal times.”

Opportunities and implications:

  • Bonfire of bureaucracy should be informed by frontline staff who have implemented these changes successfully during the pandemic.
  • There are opportunities to build and learn from the flexibility and cross sector working archived across systems and prevent not going back to how we worked before.
  • Build workforce skills around functions needed to meet citizen needs.
  • Integrated workforce around aligned objectives across organisations.
  • Integrated multi-professional leadership.
  • Align incentives around those objectives.
  • The key question is how best can ICSs support places to meet the need of distinct communities?

 

2.3 What the white paper states:

These new flexibilities will be reinforced by changes to the tariff to enable the tariff to work more flexibly within system approaches; and giving the Secretary of State the power to create New Trusts to ensure alignment within an integrated system where that is helpful.

Opportunities and implications:

  • Invest where the greatest improvements in outcomes can be made.
  • Address inequalities by investing in underlying drivers as most outcomes are not driven by health interventions
  • Without aligning financial, clinical and other drivers across place-based health and care settings it will be difficult to engage all partners in the ‘team effort’.

 

Theme 3: Improving accountability and enhancing public confidence

3.1 What the white paper states:

We are bringing forward several measures to improve accountability in the system in a way that will empower organisations. The de facto development in recent years of a strongly supportive national NHS body in the form of a merged NHS England and NHS Improvement will be placed on a statutory footing and will be designated as 12 NHS England. This will be complemented by enhanced powers of direction for the government over the newly merged body which will support great collaboration, information sharing and aligned responsibility and accountability.”

Opportunities and implications:

  • It will be important for local democratic systems to drive improvements in population health. These cannot be successfully driven by central government, save for high level public health measures. Acknowledging that the system is accountable to government.

 

3.2 What the white paper states:

An improved level of accountability will also be introduced within social care, with a new assurance framework allowing greater oversight of local authority delivery of care, and improved data collection allowing us to better understand capacity and risk in the social care system. Our measures recognise this, and we therefore plan to introduce greater clarity in the responsibility for workforce planning and a clear line of accountability for service reconfigurations with a power for ministers to determine service reconfigurations earlier in the process than is presently possible.”

Opportunities and implications:

  • A new framework for social care should empower local authorities to enhance the social care and allied workforce to meet the needs of our most vulnerable citizens:
  • Increase accessible training/skills development to broad range of professionals across all systems.
  • More apprenticeship opportunities in the community to develop further community-based care.
  • Employment opportunities should reflect the population within communities.
  • Support volunteering and VSOs as essential partners to healthcare delivery
  • Value peer support systems and encourage learning from other colleagues and systems across England.

 

Theme 4: Additional proposals which include public health, social care, safety, and quality

4.1 What the white paper states: “Our experience of the pandemic underlines the importance of a population health approach, informed by insights from data: preventing disease, protecting people from threats to health, and supporting individuals and communities to improve their health and resilience. The government will publish in due course an update on proposals for the future design of the public health system but the measures in this legislation will address issues that require intervention through primary legislation.”

Opportunities and implications:

  • There should be a clear duty to for health, care, and wellbeing partners to engage widely together with very local communities in demonstrating how the health and resilience of those communities will be improved.
  • Create aligned incentives based on population health objectives.
  • A closer alignment of local public health functions and those of health and care teams supporting local communities may reap significant benefits.

 

4.2 What the white paper states:

Following the publication of the Long-Term Plan proposals for legislation, the NHS engaged with the public, patients, NHS staff and a broad range of representatives from across the health and social care sectors on possible legislative changes. These recommendations were supported in a letter to government. NHS England’s proposals form the foundation of this Bill. Their recommendations for legislation were designed around three important principles that still stand today:

  1. Any legislation should solve practical problems.
  2. Avoid a disruptive top-down reorganisation; and
  3. Have broad consensus within the system.

Opportunities and implications:

  • With progress that has been achieved pre legislation changes avoiding unnecessary organisational restructure abs associated system inertia will be important.
  • Continued engagement with health, care, and wellbeing partners widely as well as communities will ensure.
  • Create aligned incentives based upon population health objectives and support new professional and integrated leadership.
  • Support to integrated teams across organisations to focus on neighbourhood needs and tackling inequalities in health and social care with a strong focus on prevention and public health.

 

NAPC Response Summary

The White Paper proposals were summarised and shared with NAPC membership in order to source their views and consider opportunities to ensure there remains a strong primary healthcare voice in further policy development of these legislative changes.

NAPC’s policy and influence leads are currently engaging with the Department of Health and Social Care and NHSE England and Improvement in supporting further the policy guidance development for systems on behalf of its members to ensure primary healthcare views are well represented.

 

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