The view from local government: Reconsidering accountability in an age of integrated care

There is cross-party consensus both within the Local Government Association and nationally that integration of health and social care is the right approach, particularly for improving outcomes for citizens, but also for improving value for money in the long term. But how this move towards integration works in practice is up for debate, as mentioned in Ben Jupp's viewpoint paper recently published by the Nuffield Trust.

Jeremy Hunt is clear that a strong NHS depends on a strong social care system, and vice versa. I couldn’t agree more. But recognition of mutual dependencies, while helpful, will not alone guarantee the kind of progress we need. What will? There are as many answers as there are conversations on the ground.

Transformation is neither desirable nor possible if the foundations of the system cannot be sustained. Social care needs to be placed on a firmer financial footing if it is to play its part in joining up services.

As a localist I believe that is absolutely as it should be. Anyone in the sector will tell you that the primary objective of integration is improving outcomes for individuals by building a joined-up system around them. But you’ll get a multitude of answers on how you achieve that, reflecting the particular subtleties of a particular patch.

Of course, progress with integration inevitably also plays out within the wider context for health and social care. The enormous pressure on budgets is perhaps the most inescapable issue, and dealing with this over the last four years has been extremely challenging for all councils. Spending on adult social care has been kept under control through savings worth a staggering £3.5 billion (with a further £1.1 billion planned this year), and a cross-subsidy from other council service savings of at least £900 million in 2013/14 in addition to the transfer of NHS resources to social care.

For 2015/16 that £1.1 billion transfer is part of the Better Care Fund (BCF), a joint budget across the NHS and councils with the potential to transform the way care is commissioned, designed and delivered. It is an important acknowledgement of NHS reliance on social care – evident from last winter’s A&E crisis, when councils worked around the clock seven days a week to support hospital discharge teams and alleviate NHS pressures.

But look deeper and there’s a fundamental imbalance. The BCF has become heavily NHS-focused and bureaucratised with no discernible change as a result. And on winter pressures while 25 per cent of delays leaving hospital are attributable to social care, funding is skewed massively in favour of the NHS. This reflects a wider inequality. On the one hand NHS Trusts are reporting deficits of more than £820 million and funding for health has been protected. On the other hand social care has had to make its share of major savings to return balanced budgets every year.

So what price integration for local government? Councils have a strong track record on partnership working and are fully signed up to the BCF. But, realistically, transformation is neither desirable nor possible if the foundations of the system cannot be sustained. Social care needs to be placed on a firmer financial footing if it is to play its part in joining up services.

If we can sort the money out, then there should be scope to increase the ambition and scale of the BCF, with a much greater focus on prevention. But one final piece of the puzzle still requires a bit of shaping before it slots into place: governance and accountability. This is about ensuring local governance of health and care is rooted in our local communities. The most obvious way to do this is by maximising the leadership potential of Health and Wellbeing Boards (HWBs) so they can drive local approaches to improving people’s outcomes that reflect unique local needs and other local services.

They have made a good start – joining up strategic commissioning, taking preventative approaches, and bringing all the right people to the table – but they can and should go further. That’s a challenge for all partners, but especially for councils and clinical commissioning groups. Local leaders need to ensure that HWBs feel as much a decision-making body of the clinical commissioning group as of the council. They need to establish the right size of area to cover and support all partners sharing the same information. Government should give HWBs the freedom to set their own local priorities and support this by establishing five-year funding settlements across health and care. Inspection, regulation and reporting should be integrated and proportionate as well.

This list is by no means exhaustive. There is much more to be done. But we are starting from a promising position and there is an unquestionable appetite for the work required to realise the benefits of integration. Now the Government must show its hand in how it intends to help make this happen.

This blog is part of a series of responses to Ben Jupp’s Viewpoint paper ‘Reconsidering accountability in an age of integrated care’. Share your own response in the comments below or on Twitter with @nuffieldtrust.

Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors' own.