4.The White Paper, Integration and Innovation: working together to improve health and social care for all, describes the Government’s proposals as “backing our health and care system and everyone who works in it”. The Forward of the White Paper states that this would be done by:
5.The White Paper states that the benefits of the proposals are as follows:
Integrating care has meant more people are seeing the benefits of joined up care between GPs, home care and care homes, community health services, hospitals and mental health services. For staff, it has enabled them to work outside of organisational silos, deliver more user-centred and personalised approaches to care, and tackle bureaucracy standing in the way of providing the best care for people.
6.The overarching aims of the proposals received a positive response from a wide range of organisations and stakeholder bodies. The Royal College of General Practitioners said it was “broadly supportive” of the aims of the White Paper and this was echoed by, among others, the Royal College of Nursing, the British Medical Association and National Voices. In particular, the proposal to put Integrated Care Systems on a statutory footing received support from the Royal College of Physicians, the Royal College of Radiologists, the Allied Health Professionals Federation, the Faculty of Sexual and Reproductive Healthcare the Royal College of Obstetricians and Gynaecologists and the Association of Dental Groups.
7.However, as with many submissions to this inquiry, Carers UK’s support for the aims of the Bill were caveated with concerns about omissions in the White Paper and areas that required further detail.
8.Support for the aims was also evident from our witnesses from stakeholder organisations and academic institutions, all of whom welcomed the direction of travel. The King’s Fund said that the proposals represented “a welcome shift in emphasis towards more integrated working”, and supported the proposed duty for organisations to collaborate. In a similar vein, the Health Foundation stated that the “emphasis on collaboration between the NHS, local government, and others” was welcome.
9.Stakeholder organisations were also in favour of the change in approach. The Local Government Association believed that the White Paper was:
A promising base on which to build stronger working relationships between local government and the NHS, as equal partners, to address the wider determinants of health and deliver better and more coordinated health and care services.
In particular, the LGA welcomed the renewed focus and commitment on existing local partnerships and accountability, especially at “place level” and the “creation of an ICS Health and Care Partnership to work alongside statutory NHS bodies”.
10.The NHS Confederation strongly supported the direction of travel, asserting that it was “the right approach for improving care to the public and value for money for the taxpayer”. NHS Providers also saw the proposals as providing “an important opportunity to accelerate the move to integrate health and care at a local level, replace competition with collaboration and reform an unnecessarily rigid NHS approach to procurement”.
11.Many of the proposals came at the request of NHS England in a process that started in 2014. Sir Simon Stevens explained that the White Paper was the result of “an evolution that has been under way across the health service for at least the last seven or eight years” in which the NHS had worked with a wide range of stakeholders and other organisations to “change the reality” of frontline care. He told us that around 85% of the content of the White Paper came from the proposals that the NHS had consulted on and was requesting. He concluded that the thrust of the White Paper had the support of the NHS and that the proposals “go with the grain of what people across the health service want to see”.
12.When he came before us, the Secretary of State, Rt Hon Matt Hancock, reiterated that the high-level purpose of the proposals was to strengthen integration, reduce bureaucracy, and strengthen accountability in the NHS and that they would “build on the best practice that is already out there when systems work together”.
13.We support the proposals in the White Paper that will be included in the new Bill and welcome the direction of travel in the Government’s reform of health and social care. Provided that proper accountability mechanisms are put in place, particularly relating to the safety and quality of care, we believe that creation of Integrated Care Systems throughout England has the potential to improve the delivery of care services for patients. However, there are areas in the White Paper that require further clarity or revision—and some concerning omissions which we set out in the subsequent chapters of this Report.
14.In the rest of this chapter we pick out two particular factors which will be critical to the success of the proposals within the White Paper as a whole: patient choice and Care Quality Commission ratings of ICSs.
15.The White Paper proposes placing a duty on ICSs to facilitate patient choice in relation to services and treatment. In written evidence to us, the King’s Fund highlighted improving the patient experience as a key test for the reforms; and stated that it would be “important to develop a strong narrative around the benefits the reforms will bring to patient care”. In a similar vein, the NHS Confederation highlighted the importance of protecting and promoting patient choice in order to “avoid local monopolies by continuing to work effectively […] with independent and voluntary sector providers, as well as social enterprises.”
16.However, in written evidence the Patients’ Association were concerned about how patients would be involved in the reforms. It argued that the White Paper contained “no vision for patients having any meaningful role in the planning or running of NHS services” and that there were “no firm proposals or commitments” to address this. Healthwatch also stressed that for ICSs to make “good, well-informed decisions” it was vital that local people had a way of formally inputting into the process. Healthwatch also emphasised the need to facilitate patient choice for disadvantaged communities and for other groups such as parents. The Royal College of General Practitioners also noted that reform would not deliver the intended outcomes unless there was an appropriate level of focus on “facilitating collaboration between clinicians and patients”.
17.The Nuffield Trust also saw the effect of the reforms on patients as a key test and emphasised that the Bill, when presented to Parliament, needed to retain the ‘Any Qualified Provider’ model for elective care, where “commissioners fund any organisation meeting standards which provides elective care at a rate per patient who chooses that provider, and the legal right of choice for a first appointment”. The importance of patient choice was also highlighted by the British Dental Association who believed that services needed to be delivered locally wherever possible and that patients must be able to seek treatment across ICS and Primary Care Network boundaries.
18.When we questioned Sir Simon Stevens on this, he agreed that the ability for patients to have the choice as to where they receive their care, both within an ICS area and outside of it [our italics] had to be retained. This was echoed by the Secretary of State when he gave evidence to us. He said that retaining choice was “very important” and that the “fundamental split between commissioning and provision of services” would remain.
19.We welcome the Secretary of State’s confirmation that the statutory right of a patient to choose where they receive treatment will be retained in the forthcoming legislation. We welcome the Secretary of State’s commitment to this and look forward to seeing provisions in the Bill to maintain and enhance patient outcomes and to retain the patient’s right to receive treatment outside the area served by their local ICS.
20.Assessing the effectiveness of Integrated Care Systems will be a key part on judging the success of the proposed reforms. When we put it to Sir Robert Francis, Chair of Healthwatch, that the Care Quality Commission (CQC) should rate ICSs he agreed that this would be a positive step and that there were two audiences for ratings, “one is the taxpayer and those that represent the taxpayer. Are we getting what we are paying for?”
21.Chris Hopkins noted that the CQC had played a valuable role in system reviews and that it made sense to use the CQC for assessing ICSs, and Danny Mortimer agreed that “ICSs absolutely need to be held to account”. He also noted that:
The conversations that we have had over recent months with both NHS England and the CQC have given us some assurance that those organisations recognise that they need to revisit and change their ways of working.
22.Sir Simon Stevens was also receptive to the CQC providing Ofsted-style ratings and highlighted the “important” developments of the CQC inspection regime in relation to its thematic reviews. He asserted that “having that focus across individual providers in the ICS will be of great value”. He further noted that any CQC review of the ICS would need to focus on “mandate goals and the long-term plan deliverables that have been set, so that there is complete accountable alignment through the service”.
23.In response to this suggestion, the Secretary of State confirmed that the Government would “ensure, as part of the Bill, that the CQC will be able to inspect how well systems are doing and publish on that basis, including setting out the high-level, four-part report—Outstanding, Good, Requires Improvement and Inadequate—that everybody knows and understands”.
24.We welcome the Secretary of State’s commitment to include in the Bill, at our suggestion, provisions to enable the Care Quality Commission to undertake ratings of Integrated Care Systems. As an independent regulator it must for the CQC to decide how such inspections and ratings work but we note that the success of the system to date has been partly because the core domains (safe, effective, caring, responsiveness and governance) are largely patient-facing, so it is essential such an approach is maintained including a domain that focuses on safety and quality and is named as such. We believe within these domains it should be possible to include assessment of delivery of core NHS England and DHSC objectives so that there is alignment of objectives across the system.
27.The White Paper envisages that the reforms contained in the White Paper would be implemented in 2022. Given the exceptional strain that has been placed on the NHS and local authorities during the covid-19 pandemic, a number of our witnesses questioned the need to set what they considered to be a challenging implementation timeframe. The Nuffield Trust highlighted the 2022 timetable, in the context of the very “serious operational challenges the NHS is likely to see”. The Health Foundation agreed. It described the challenges facing the NHS after covid-19—the backlog of unmet health care need, fixing chronic staffing issues, and working with others to tackle wide and unjust health inequalities—as “staggering”. NHS Providers also argued that the Government needed to “reflect on the appropriateness of changing the structure of the NHS at a time when it is operating on a crisis footing when frontline staff need absolute clarity about ways of working” and urged the Department and NHSE/I to “seriously consider extending the timetable for developing and implementing these proposals”, in light of what is an “extremely challenging time for the NHS” with Trusts needing to “stabilise the service and recover the care backlog”.
28.In its submission, the British Medical Association highlighted that the reforms would be introduced at a time when the NHS was experiencing unprecedented pressures; and that “proposals for reorganisation on such a scale must be given time and space to get right and not be rushed through while doctors are still dealing with the aftermaths of a worldwide pandemic”. The effect of implementing the reforms in the context of the pandemic was also raised by the British Dental Association and the Chartered Society of Physiotherapy and Professors Judith Smith, Jon Glasby and Robin Miller at the University of Birmingham.
29.However, although the NHS Confederation believed that the Government needed to be “mindful of the timeline for implementing [the] measures” it argued that many of the proposals in the White Paper would “merely formalise how our members are increasingly operating.” This view was supported by Sir Simon Stevens who argued that the timing of the proposals and the implementation were both necessary and achievable:
Yes, as the NHS we would ask that Parliament gives attention to this matter during the course of the coming year. The reason is that it is not coming from a standing start. It is almost the concluding stage of an evolution that has been under way across the health service for at least the last seven or eight years. It began back in 2014 with the NHS five-year forward view.
Sir Simon confirmed that the NHS had “done nine tenths of what we are able to do”, but that the final tenth “requires changes to the 2012 Act, to get rid of some of the fragmentation”. He concluded that this was why the NHS was seeking approval to make those changes in the proposed timeframe. For some areas this would be easier than others. Amanda Pritchard, Chief Operating Officer, NHS England and NHS Improvement, explained that different parts of England would be starting at different points:
For some parts of the country that have been on this journey, and been very serious about integration, for some time, it removes the remaining barriers for them, to make it as easy as possible. For other places, it is much more about putting some of the foundations in place.
On the timing of the reforms, the Secretary of State reiterated that “the vast majority” of the proposals came from NHS and reflected the needs of local authorities. For that reason, he saw no benefit in delaying the process.
30.While we accept the importance of the timely implementation of the proposed Bill, we recognise the concerns raised by our witnesses about the effect this may have on the NHS and the care sector; both of which have been put under unprecedented strain during the covid-19 pandemic. The Government must be alive to the need for flexibility in the timetable for implementation as the scale of the post-pandemic backlog becomes clearer.
a)The Department and NHS England ensure that processes are in place to share best practice quickly and effectively so that all areas can implement these reforms efficiently, with additional practical support mechanisms offered to ICSs that get low CQC ratings;
b)The implementation period takes into account fully, the fact that parts of the country will be at different starting points on this journey; and
c)Local NHS leaders have a role in setting the pace of the implementation to ensure that the establishment of ICSs will not adversely impact an area’s covid-19 response or recovery.
1 , Forward
2 , Forward
3 , Executive summary, 1.9
4 The Royal College of General Practitioners ()
5 Royal College of Nursing ()
6 BMA ()
7 National Voices ()
8 The Royal College of Physicians ()
9 The Royal College of Radiologists ()
10 Allied Health Professions Federation (AHPF) ()
11 The Faculty of Sexual and Reproductive Healthcare and The Royal College of Obstetricians and Gynaecologists ()
12 Association of Dental Groups ()
13 Carers UK ()
14 King’s Fund ()
15 Health Foundation ()
16 Local Government Association ()
17 Local Government Association ()
18 NHS Confederation ()
19 NHS Providers ()
23 , para 5.37
24 King’s Fund ()
25 NHS Confederation ()
26 The Patients Association ()
27 Healthwatch ()
28 The Royal College of General Practitioners ()
29 Nuffield Trust ()
30 British Dental Association ()
38 Nuffield Trust ()
39 Health Foundation ()
40 NHS Providers ()
41 NHS Providers ()
42 BMA ()
43 British Dental Association ()
44 The Chartered Society of Physiotherapy ()
45 Professor Judith Smith, Professor Jon Glasby and Professor Robin Miller at the University of Birmingham ()
46 NHS Confederation ()