The Health Devolution Commission set out in its Levelling Up Health report that the 42 new Integrated Care Systems should each be a genuine partnership of equals between the NHS and local government if they are to achieve their ambitious aims of improving the population’s health as well as providing better and more integrated health and social care systems. Unfortunately, the current Health and Care Bill does not create the necessary statutory basis for such an equal partnership.
Now the Parliamentary Select Committee for Local Government has flagged its concern. Their recent report Progress towards Devolution categorically concludes: ‘The proposals of the cross-party Health Devolution Commission should be the basis for health devolution.’ However, the Health and Care Bill has only one clause which refers to the need to establish an Integrated Care Partnership (ICP) whilst the Integrated Care Board (ICB) warrants eight clauses. It is particularly notable that there is no legislation to provide for:
- a clear constitution for governance and membership of ICPs including clarity that the chair of the ICP should be a democratically elected person (local authority or combined authority);
- clarity about how ICPs will produce their Health and Wellbeing strategy for their ICS including arrangements to have funding and the capacity to employ staff;
- appropriate power and mechanisms for ICPs to hold ICBs to account for ensuring their plans comply with their strategy
- a vice-chair of the ICB being a democratically elected local or combined authority leader.
The Health Devolution Commission has wrestled with the issue of the extent to which partnerships of equals can and should be mandated. The Commission recognises the value of the permissive nature of the legislation as currently framed in providing significant flexibility for local partners to develop their Integrated Care Partnerships in ways that reflect local circumstances and relationships. And it is acutely aware that legal requirements to form genuine and effective collaborative working are not sufficient to make them a reality – that of course requires hard work to build strong relationships between system leaders, middle managers and frontline staff across health, social care and public health.
But the Commission is equally aware of the long history of a major imbalance between the respect, funding, and workforce conditions for NHS and social care sectors. Perhaps the cruellest and certainly most recent example is the Health and Care Levy. A £12bn per annum levy notionally created to ‘get social care done’ is 85% being used to fund the NHS, not social care. Is it sufficient to rely on the goodwill and benevolence of the NHS to create a partnership of equals?
NHS England has now produced – very welcome – guidance on how on how Integrated Care Partnerships should work in practice, on creating Place-based Partnerships within ICSs, and on developing Primary Care Networks in smaller localities. But history tells us that when push comes to shove, and when the power and money lies with the NHS, then support for social care and services that tackle the causes of ill-health or reduce health inequalities go to the back of the queue.
The CLG Committee noted the Commission’s concern that unless we are careful the Health and Care Bill will lead to more centralisation and not genuine devolution and partnership. It went as far as to propose that the chair of the ICB should be chosen by local partners and not appointed by the Secretary of State. It also endorsed the Commission’s views that the ICB should have one vice-chair from the NHS and one from local government, and that the ICP board should be chaired by a local government leader or metro mayor.
There has been no time for these issues to be properly considered by the Bill Committee in the House of Commons which has as usual rushed through its business. The House of Lords will have another opportunity to consider the benefits of strengthening the role of the Integrated Care Partnership. These would include positive engagement of all partners in the Integrated Care System; enhanced efficiency and effectiveness if integration benefits are found; the opportunity to impact on a greater range of drivers of ill health for example poor housing; and a more motivated leadership and workforce if it is really a partnership of equals.
This is not an argument about who has a seat at the table. Power relations based on legal rights and duties are important in partnerships. The cross-party Health Devolution Commission, with the support of the cross-party Select Committee, will continue to make the case for a genuine partnership of equals between the NHS and Local Government. Parity of esteem between health and social care, and a fundamental shift in priorities from a singular, top-down focus on clinical care to a broader, locally-led strategy for improving the health of everyone in our communities is essential.
Phil Hope is former minister of state for care services, and Steve Barwick is director of the Health Devolution Commission