LGA position paper on Integration

This paper outlines the learning from the LGA and its partner organisations on the critical success factors for achieving effective, joined-up and person-centred care and support to improve people’s experience of care and support and improve their health and wellbeing outcomes.

Introduction - What is the purpose of integration?

The LGA is a long-standing and committed advocate of integration. But integration is not an end in itself. It is an approach to achieve better health and wellbeing outcomes through joined-up planning and resourcing, and joined- up care and support. In 2016, together with NHS Confederation, NHS Clinical Commissioners and the Association of Directors of Adult Social Services, we called for a change of gear to accelerate the scale and paces of integration to achieve our shared vision for integrated care. The shared vision is:

"Services that are organised and delivered to get the best possible health and wellbeing outcomes for citizens of all ages and communities. They will be in the right place – which is in our neighbourhoods, making the most of the strengths and resources in the community as well as meeting their needs.

Care, information and advice will be available at the right time, provided proactively to avoid escalating ill health, and with the emphasis on wellness. Services will be designed with citizens and centred on the needs of the individual, with easy and equitable access for all and making best use of community and voluntary sector provision. And they will be provided by the right people – those skilled to work as partners with citizens, and who enable them to be able to look after their own health and wellbeing.

Leaders – local and national – will together do what is best for their citizens and communities ahead of institutional needs. It means directing all of the resources in a place – not just health and care – to improving citizens’ wellbeing, and increasing investment on community provision. It also means sharing responsibility for difficult decisions, particularly in securing sustainable and transformed services.”

Almost six years on, this remains the vision to which we should aspire. Though there have been real strides towards moving integration from the margins to the mainstream of planning and delivery, we still have a long way to go. Many of the building blocks are already in place across the country. In many parts of the country, health, local government and other sector partners are forging ahead with integration. We need to avoid disrupting the progress by introducing structures or initiatives unless there is a well-evidenced need and benefit.

The Health and Care Bill aims to embed and strengthen integration within the NHS and between the NHS and local authorities, through the creation of integrated care boards (ICBs) as statutory NHS bodies and integrated care partnerships (ICPs) as statutory committees. Senior leaders from the NHS, local government, our partners in the voluntary and community sector and people with lived experience, however, all agree that legal duties and structures are only part of the foundation for effective integration. This paper outlines the learning from the LGA and its partner organisations on the critical success factors for achieving effective, joined-up and person-centred care and support to improve people’s experience of care and support and improve their health and wellbeing outcomes.

What can we achieve through effective integration?

The characteristics of effective integration outlined below are drawn from our learning from leading edge areas.

For individuals:

  • Information, advice and support give people choice and control to enable them to take care of their own health and wellbeing
  • when people need health and/or social care, this is co-produced between individuals, their carers (where relevant), and multi-disciplinary teams of professionals and the voluntary and community sector based on a holistic, enabling approach to support people to live full lives and maximise their independence
  • the most appropriate care, in the right place at the right time to maximise health, wellbeing and independence
  • confidence that services are safe, effective and accountable.

For communities:

  • preventative services supporting communities to be active, safe and making the most of their own strengths and assets
  • as taxpayers, the confidence that care and support is safe, effective and is the best use of resources, and based on evidence of what works
  • services that are locally accountable – people are engaged in identifying local priorities for integration and in reviewing the progress and impact of integration
  • a preventative approach that reduces the need for specialist health and care support, and addresses health and wider inequalities.

For planners and providers of care and support:

  • collective leadership working to achieve a shared local vision for improving health and care outcomes
  • joint or aligned strategies and resources to invest in care and support focused on achieving better population health outcomes and reducing health and wider inequalities
  • a shared evidence base to inform priorities, track progress and benchmark with other areas
  • shared information systems to join up care around the individual and to prevent people falling through gaps between services
  • neighbourhood- and place-based multi-disciplinary teams – including the voluntary and community sector – working together to join up care and support around the whole person, maximising their independence and confidence to look after their own health and wellbeing
  • a learning culture in which professionals and individuals with lived experience contribute their perspective and expertise as equal partners in order to improve care and support.

For health and wellbeing boards and integrated care systems:

  • a clear understanding of where the place or system can add value to the planning and provision already happening at neighbourhood, place or system level to join up care and support to achieve better population health and wellbeing outcomes
  • a strong focus on early intervention, to give people the information, advice, care and support they need to maintain their own health and wellbeing, and also to reduce demand for more intensive health and care interventions
  • clear agreement between leaders at all levels of the governance structure, working on the principle of subsidiarity, that decisions are taken at the most local appropriate level
  • a learning culture in which all the places within a system can learn from best practice, and work together to address unwanted variation in service quality and health and care outcomes – informed by a shared evidence base.

For Government and national bodies:

  • a permissive and enabling culture, and increasing devolution and delegation, which gives local health and care leaders the freedom and flexibility to develop and deliver plans and strategies that are right for their populations
  • an understanding that the most effective drivers of integration are collaborative leadership, an emphasis on place-based planning and delivery, and a shared culture which focuses on population outcomes, rather than NHS activity (Integrated care: Our position, The King's Fund)
  • setting out expectations for outcomes within a single outcomes framework across health, social care and public health, which has place-based, person-centred and preventative care and support at its core
  • a light touch, sector-led improvement programme to assure that all systems and places have the right resources, skills, processes and relationships to achieve their shared ambition
  • a long-term and sustainable funding and financial system which incentivises investment in community-based, joined-up and preventative care and support.

What are the most effective drivers of integration?

Collaborative place-based leadership

Local authorities are the convenors and connectors at place level. Through health and wellbeing boards (HWBs) and other partnerships, they are forging a collaborative culture in which partners from the NHS, local government, the community and voluntary sector, and communities themselves all contribute to joining up care and support. Place leadership – especially HWBs – is crucial to driving integration in partnership with ICSs.

  • LGA offer LGA is committed to working with the Government and NHS England (NHSE) to develop a light-touch sector led improvement support offer to ensure HWBs all meet minimum requirements for leading on integration. The support offer will be based on a national assurance framework setting out the expectations for all HWBs. The core elements will focus on leadership, culture, behaviours, a shared evidence base, shared resources, joint strategies and clear governance arrangements.

Place as the primary building block of integration

Decision-making as close to communities as possible, with place usually being the most appropriate and effective level for driving joined-up care and support (Tackling delayed transfers of care in Bradford District and Craven).

ICSs will need to ensure that their place-based partnerships are either co-terminus or align as closely as possible with local authority places, since this is the footprint of many services they will need to work with – adult social care, children and young people’s services, housing providers, the community and voluntary sector.

  • LGA offer – to provide examples of good practice of place-based action to join up resources, planning and delivery of integrated care and support, with evidence of an impact of better outcomes for individuals and populations.

Build on existing, successful local arrangements

We already have place-based structures and processes at place for driving integration.

  • The Better Care Fund (BCF) has been a major impetus for local authorities and clinical commissioning groups to pool resources to join up the commissioning and provision of care and support. This has prevented hospital admissions, and when people do need hospital care, it has ensured that people have the right care and support to be discharged safely to resume their lives. In recent years however, the BCF has been dominated by the objectives of acute trusts to reduce delayed discharges and hospital length of stay. While both these objectives are important, a focus on these has drawn attention and resources on getting people through the ‘back door’ rather than on preventing people needing inpatient care in the first place.
  • To better fulfil the ambitions around integration, the BCF should return to its original aspirations: to provide the right care, in the right place, at the right time in order to enable people to live independently within their homes, and when they need care and support to access this as close as possible to their home (Health and social care integration, National Audit Office. This means also a more equal and balanced relationship between the national BCF partners – the Department of Health and Social Care (DHSC), the Department for Levelling Up, Housing and Communities, NHSE and the LGA – in agreeing the policy framework and the national conditions and planning requirements (Leading for integrated care, The King's Fund and 2021 to 2022 Better Care Fund policy framework).
  • Section 75 arrangements the BCF is just one of the pooled budgets that many local government and health partners use to fund joined up services. In many areas, integrated services for people with learning disabilities and mental health needs are funded through Section 75 agreements (Integrating health and social care: North East Lincolnshire case study). We want to see far greater use of S75 arrangements to pool budgets and support, utilise lead or joint commissioning arrangements, and provide integrated or aligned provision so that preventative services are available in every place, and people can easily access the care and support they need to maximise their health, wellbeing and independence.
  • Health and wellbeing boards are the statutory place-based forum for bringing together the professional, clinical, political and community leaders of a place to develop a shared evidence base (the joint strategic needs assessment) and agree a shared vision and priorities (the joint health and wellbeing strategy) to improve population health and wellbeing outcomes and address health and wider inequalities. HWBs have had a major impact on improving relationships across health and local government, championing change, driving integration and connecting with communities (What a difference a place makes: the growing impact of health and wellbeing boards). ICSs have a ready-made place-based forum to build on and link to in their place-based partnerships.
  • HWBs as the governance for the key integration vehicle will need to be underpinned by joint or lead commissioning teams and other staff to deliver the local visions for integration.
    • LGA offer – the LGA has a well-established and well-regarded sector-led support offer to help HWBs to improve their effectiveness as the key place-based connector and driver of integration, and to be supported by appropriate commissioning and/or delivery architecture. We are committed to working with Government and NHSE to develop our improvement offer to ensure that all HWBs are effective drivers of the integration agenda at place, and work effectively with ICSs.
  • Additional leverage for HWBs to lead further integration – we believe that some HWBs are ready to take on additional responsibilities for joining up health and care services. We propose a pilot programme, funded by Government, to enable a small cohort of places to establish full joint or lead commissioning of some or all place-based community health and care services, with the HWB providing oversight and governance. This could include learning disabilities, mental health and physical disabilities, but precisely what is to be joined up should be determined as part of the bidding process. We will work with places to shape their proposals.
  • Within these areas, there is the potential for the local authority chief executive to have a key role as the place based leader across health and care, similar to the current arrangements in some areas in which local authority chief executives are also the CCG chief officer.
  • The accountability for enhanced and extended integration pilots would be to councils and the ICB through the HWB in the same way as existing S75 pooled budgets and lead commissioning arrangements are overseen. The learning from the pilots will inform the further development of integration, with the ambition for all HWBs to have the flexibility to assume this responsibility. And devolution to place should be part of the framework of any reforms, and not just limited to the pilot areas.
  • LGA offer – we will work with the Government and NHSE to develop the pilot programme and to select leading edge HWBs. We will also work with the Government and NHSE to evaluate the impact of the pilot HWBs in joining up care and support to improve outcomes, and share the learning through our sector-led improvement offer. We will also support the chosen pilots to draw together a wider range of health and care services to provide better coordinated access, experience and outcomes to local people – looking for areas to be ambitious about what they can achieve.

A person-centred and co-productive approach

To ensure that integrated care and support enables individuals to live full and independent lives, rather than mired in structures and processes. National Voices sets out clear expectations of what people and their carers want from integrated care (Integrated care: what do patients, service users and carers want?):

  • The aspects of care correlating most closely with good patient experience are relational. People and their carers want to be listened to, to get good explanations from professionals, to have their questions answered, to share in decisions, and to be treated with empathy and compassion.
  • The people for whom integration is most relevant, those with long-term conditions or complex care needs, want the ‘system’ to combine two things in one place. They want knowledge to be seen as a whole person, and for professionals to consider their home circumstances, lifestyle, views and preferences, confidence to care for themselves and manage their condition(s), as well as their health status and symptoms. They also want knowledge of the relevant condition(s) and all options to treat, manage and minimise them, including knowledge of all available support services.
  • Increasingly, multi-disciplinary teams from across the NHS, adult social care, the voluntary and community sector and housing are working together with individuals and their carers at place and neighbourhood level to support and enable individuals to live a full life (Integrating health and social care: Nottingham case study). ICSs need to enable existing person-centred support and to work with place-based leaders to develop them further (People helping people: Year two of the pioneer programme).
Wirral care home triage: Wirral has a large number of care homes and had a significant number of non-elective admissions from care home residents. They introduced a tele-triage service across 76 care homes, which gave an iPad and basic monitoring equipment to staff, who could use this to call on the advice of a nurse practitioner or GP when a resident become unwell. The service receives around 300 calls a month and only 15 per cent of residents require hospital treatment following the consultation. In terms of impact, there has been a 68 per cent reduction in NHS 111 calls from Wirral care homes, and a 10 per cent reduction in ambulance conveyances to A&E from care homes for 2018/19 compared to 2017/18 (Wirral: care home teletriage service).
  • LGA offer – to work with the Government, NHSE and other national partners to identify and share learning and good practice examples.

A preventative, assets-based and population-health management approach is the basis for improving health and wellbeing outcomes. The integration of health and care is often focused on supporting those with existing health and care needs. But we also need to refocus and reinvest in preventative and health-promoting services to enable people to maintain their health and independence (Integrating health and social care: Nottingham case study). In local authorities, public health teams lead the strategy for prevention, working closely with HWBs. Place-based health functions and councils including public health teams need to be adequately resourced so that they can invest in preventative measures.

Voluntary Action Rotherham is funded £500,000 to allocate money to voluntary and community organisations that are providing activities as part of its social prescribing programme. Analysis has identified an overall trend that points to reductions in service users' demand for urgent care interventions after they had been referred to the social prescribing programme. The estimated total NHS costs avoided between 2012-15 were more than half a million pounds: an initial return on investment of 43 pence for each pound (£1) invested (Integrating health and social care: Rotherham case study).
  • LGA offer – to work with the Government and NHSE to develop and share learning and good practice examples, and to continue to provide support to systems in how to develop and invest in preventative community models of health and care.

Achieving best value

We acknowledge that there is limited evidence that integration reduces the costs of care and support and /or improves access and outcomes. We need a stronger evidence base that pooling health and care resources is the most effective use of resources. We do, however, have some evidence on which to build a better understanding.

For example, a common problem across many systems is the over-prescription of care, where people are given a higher level of support than they actually need. There is evidence that multi-disciplinary teams are more consistent at prescribing support at the ‘right’ level. The LGA report on better management of hospital admissions found:

By focusing on the best care pathway for patients or service users , significant benefits can be realised in terms of improved outcomes, greater quality of services and financial savings. Efficiency savings of 7 to 10 per cent of the budget areas assessed in this project could be realised through approaches to health and care that are better integrated. This equates to efficiency savings of over £1 billion nationally across the health and care system" (Efficiency opportunities through health and social care integration: delivering more sustainable health and care).

  • LGA offer – to work with the Government and NHSE to strengthen the evidence base for achieving the best use of resources through integration.

Flexibility and freedom of local leaders

We need to maintain and extend these in order for leaders to work together to agree shared ambitions that are right for their populations, taking into account their unique demography, health and care challenges, history of partnership working and health and care resources (West Yorkshire and Harrogate Health and Care Partnership). The top-down approach of national targets and priorities is a major barrier to them keeping a sharp focus on achieving local priorities for providing integrated care and support.

We recognise the Government’s role in setting the national policy agenda for integration, and in setting out national expectations but this should be a broad enabling framework rather than a prescriptive and directive approach to how and where resources should be deployed. It will be vital that NHSE, council and CQC self and formal assurance and performance monitoring processes expect and assess for progress on the greater integration of services at place, improved experience of people using services or needing information and extension of preventative services.

Evidence shows that local systems can most effectively address their challenges when they have the freedom and flexibility to find their own solutions. The imposition of top-down national conditions and targets also undermines the message that local health and care leaders have a responsibility to meet local challenges. For example, with regard to BCF, the national targets on delayed transfers of care may have led to temporary reductions but not necessarily the best outcomes for individuals, with funding and attention diverted from preventative, community based interventions. We need to work with place leaders so they own their own performance aimed at achieving sustainable improvements.

What can the Government do to support integration?

In the main, we already have the mechanisms and structures to escalate the scale and pace of integration. We also have a clear vision for what integration can achieve. What we need now is for the Government and NHSE to give local place-based leaders the freedom and flexibility to drive this agenda according to what works for their local communities.

We call on the Government to:

  • clearly refocus the aim of integration to achieve better population health and wellbeing outcomes, rather than focusing predominantly on addressing the immediate pressures of acute hospitals
  • emphasise that integration is characterised by a place-based, person-centred and preventative approach
  • work with the LGA and NHSE to agree a broad national framework of outcomes and expectations for integration
  • give local leaders the flexibility, freedom and support to set their own ambitions and priorities for integration on the basis of the unique characteristics, resources and challenges of their populations
  • reinforce the primacy of place-based health and wellbeing boards and joint teams that support them as a key driver for integration
  • work with the LGA to develop a pilot programme for places with leading edge health and wellbeing boards to extend their responsibilities for commissioning community-based health and care, evaluate the impact and share the learning through the LGA’s sector-led support programme
  • restate the original intentions of the BCF to include investment in prevention and early intervention
  • maintain existing mechanisms for integration, notably Section 75 arrangements and the BCF
  • work with the LGA to develop our sector-led improvement offer to ensure that all health and wellbeing boards are effective leaders of integration at place
  • promote a culture of collaboration and shared learning in the NHS and local government that minimises top-down direction
  • ensure that public health, adult social care and community based health services – GPs, community mental health, occupational therapy and services for special educational needs and disability – have adequate and sustainable funding for integration to improve outcomes.
  • LGA offer – to work with DHSC and NHSE to develop a permissive and enabling national framework that sets broad national expectations and gives local leaders the freedom and flexibility, a more robust evidence base and a (self) assurance framework and support offer to ensure that local place-based leaders – health and wellbeing boards – are fit for purpose.