Guest article: DHSC whitepaper on health and social care integration – Several ideas in search of money and staff
In this article, William Lee, Policy and Parliamentary Executive of the British Healthcare Trades Association (BHTA), has welcomed the UK Government’s plans for data sharing and a focus on outcomes in its recent integration whitepaper but has called for a detailed, actionable plan to join up care across people, places and populations.
On 09-Feb-22, the Department of Health & Social Care (DHSC) published a whitepaper, ‘Health and social care integration – Joining up care for people, places and populations’, that “sets out measures to make integrated health and social care a universal reality for everyone across England, regardless of their condition and of where they live.”
The paper seeks to put more meat on the bones of the UK Government’s 10-year vision for adult social care, ‘People at the Heart of Care’ (01-Dec-21), which provided the first look at health and social care proposals that will be funded by the £1.8 billion-per-year increase earmarked for social care from the imminent (01-Apr-22) 1.25 percent rise in National Insurance contributions levy (£5.4 billion total over three years).
We welcome several of the aims set out in the whitepaper, including:
- Plans for data sharing (Section 4) across the NHS and local authorities so that service delivery is faster, less fragmented, and frees patients from having to repeat the same information to multiple caregivers (with a goal to have digital, shared care records for all by 2024; this is especially important for those suffering from complex and/or multiple diseases and disorders). Past NHS IT and data projects, however, have almost always proven more complex, expensive, and disruptive than anticipated, and we support the call from the Alzheimer’s Society to ensure that plans in this area do not interfere with the urgent need for critical, non-emergency services to return to normal.
- A focus on outcomes not outputs (Section 2) for organisations across health and social care, with implementation of shared outcomes to begin from April 2023. There are already encouraging examples of as-was clinical commissioning groups (CCGs)/emerging integrated care systems (ICSs) working toward shared goals, designed with citizen-input and grounded in the needs of local populations. We support these consultative and locally driven approaches, which have long been called for by the NHS Confederation and others.
We’re less sanguine about plans for single-local-leader accountability for delivery of shared outcomes at the “place” level within ICSs, and goals to “encourage” NHS and local authorities to do more to align and pool budgets (Section 3). Both of these ambitions are highly susceptible to a weakness highlighted in the whitepaper – past “[over]reliance on relationships and ‘soft’ levers, [which] can work well in areas where there are strong relationships, but are vulnerable to changes in leadership,” and are not back-stopped by structural accountabilities (p. 26). No alternatives or augmentations to address these vulnerabilities (outlined cogently by NHS Providers) are suggested – and, as the Health Foundation points out, “better integration between services is no replacement for properly funding them; the social care system in England is on its knees and central government funding over the coming years is barely enough to meet growing demand, let alone expand and improve the system.”
Most concerning of all, however, is the lack of detailed attention to the health and social care workforce (Section 5). There is a welcome show of support for training and development of staff (in social care), but no consideration of the broader panoply of workforce issues (vast vacancies, difficulty in recruiting/retaining staff, lack of incentives to choose health and social care as profession), as illustrated by a chorus of responses to the whitepaper:
- “Welcome steps [. . .] but none of this is possible without the workforce to provide that care.” (Royal College of Physicians)
- “There was no mention of a national workforce plan [. . .] and integration must encompass and involve the whole of the social care sector from local authority commissioners, through to voluntary and small and medium enterprise (SME) providers of care.” (Skills for Care)
- “More integration is little good if there aren’t enough staff to deliver services – staffing shortages in health and social care are chronic, yet Government has no long-term plan to address them.” (The Health Foundation)
Many would point out that integrating health and social care – both as a large-scale ambition and as an actual, on-the-ground occurrence in certain parts of the UK – is not new. And, indeed, the paper is shot through with examples of successful integration projects and programmes already underway. The rest of the paper sets out some admirable ambitions to promote closer integration of health and care, and rightly acknowledges that there is no single, one-size-fits-all approach. But again, as BHTA highlighted in our comment on the UK Government’s 10-year vision for adult social care, if the goal is to join up care across people, places and populations, a detailed, actionable plan is required – and this paper is still more “journey-planner” than actual plan. On this point we echo the sentiments of the NHS Confederation:
“This is the latest in a long line of whitepapers over recent decades that have tried to better integrate services [and] the critical question, therefore, is ‘What will this whitepaper enable which cannot already be done?’ The answer to this appears to be ‘very little’.”