For integration to work, local authorities and the NHS must be equal partners
Updated: Apr 6
Integrating health and social care means creating a coherent system out of the existing muddle of local government and NHS structures, writes John Copps. (A version of this article was published in the HSJ on 22 September 2016 – click here.)
The formidable challenge of how to integrate two divergent systems – the health service and the social care system – is at the core of the long term sustainability of public services.
A key ingredient in this is closer working between the NHS and local government. This is a nut that is yet to be cracked.
A path to transformation
The latest attempt to push the integration agenda is the Sustainability and Transformation Plans (STPs). STPs bring together local partners to map out a path to transformation over the next five years, addressing the challenges laid out in the Five Year Forward View.
Announced earlier in the year, the 44 STPs are based on geographical “footprints”, which NHS England describes as “locally defined, based on natural communities, existing working relationships, patient flows and taking account of the scale needed to deliver the services”.
Yet these footprints highlight what is the biggest practical barrier to integrated working between NHS and local authorities: the complex institutional infrastructure around health and social care.
Our system of local government and the NHS is an unholy muddle: a patchwork of diverse institutions co-existing across overlapping boundaries, many of which are artefacts of previous re-organisations. If you were to design it from scratch, you wouldn’t end up with what we have.
Take Lincolnshire as an example: an area with four clinical commissioning groups, two foundation trusts, one county council, seven district councils, and one community healthcare provider – none of which have the same geographical boundary. Complexity abounds.
Moreover, contained in these infrastructures are competing interests, divergent funding flows, and contrasting working cultures. STPs will live or die by their ability to knit this all together and create something like a coherent system.
So how can this be achieved, and which elements of the STPs will make the difference to forging a productive partnership between the NHS and local authorities?
First, as in any transformation, leadership is all important. On the face of it, STPs are an initiative colonised by the NHS – only four of the 44 STPs are led by local government (including Nottinghamshire, Birmingham, and Manchester). Inevitably this has led to grumbling that it is not a partnership of equals.
Nominated leaders in the NHS must work hand-in-hand with local authorities to ensure all the benefits of integration can be explored. Getting the governance right, including making sure local authorities have a seat at the top table and that politicians stay engaged, must be a priority in the bids.
Second, STPs must be sensitive to the differences between partners. Local authorities have coped with multiple years of budget cuts, while the NHS has seen demand-side pressures. Local authorities have to bow to direct local democratic control, while the NHS doesn’t have to react in the same way.
There are dependencies around hospital beds and care placements that can put pressure on both sides. This can create tensions that need to be managed carefully within the STP. Partners must coalesce around a clear vision and promoting their common goal of better healthcare for the local population.
Third, financial incentives must be aligned and budget holders given the space to talk to each other. STPs are about partners coming together to manage collective resources. There are already existing models for this, for example Section 75 agreements that are used to pass budget and commissioning responsibilities between the NHS to local authorities. Where it works well, good practice should be built on.
One of the drivers of the STP process is the recognition that the financial pressures faced across the healthcare system cannot be tackled in isolation. Collaboration opens up opportunities for efficiencies, among them the not-often-mentioned disparity in rates charged by suppliers to the NHS and local authorities.
Where this takes us in the future is uncertain but The King’s Fund has raised the prospect of “system control totals”, or a mechanism to enforce an aggregate financial target across whole footprints.
Time is running out for areas to whip their plans into shape for the 21 October deadline for submission to NHS England. The process has already had its ups-and-downs and, with such high stakes, we can expect more to come.
However, by encouraging whole system thinking, and binding together local authorities and the NHS, STPs offer an opportunity to shake up health and social care for the better. We may look back on this moment as a significant step forward.