Health and care – where are we and what does the winter hold?


By Eleanor Roy, CIPFA Health and Social Care Policy Manager

Winter is coming, and with it, speculation as to whether we might enjoy a more 'normal' festive season this year. We don't yet know what the path through winter will look like for COVID-19, but other shadows such as rising energy prices, queues at petrol stations and the fear of empty shop shelves are looming large and threaten to impede the passage of Santa's sleigh.

What is certain is autumn and winter will be busy for the health and care sector – as it always is. The usual parade of colds, flus and other winter bugs all increase demand for services. As we've all been less exposed to these over the last 18 months, an increase in such infections is unfortunately anticipated.

As for the impact of COVID-19, the jury is still out. The success of the vaccination programme across the UK means there should, thankfully, be fewer instances of serious illness than last year. That said, urgent and emergency care has seen continued pressure through the summer months. Once we are all huddled together indoors avoiding the cold and wet weather, it is likely that we'll see increased infection rates – but how much of a toll this will take on the sector remains to be seen.

Whatever the winter brings, there is a focus on one word across both health and social care services: recovery. We hear much about the NHS backlog, but social care is also having to play catch up. Nearly 300,000 people are waiting for care and support, initial assessments or reviews of existing care plans. Let's be clear: these waiting lists are not a new problem as they existed long before we had ever heard of the coronavirus – but it has certainly grown them! The one certainty about waiting lists is that while people are waiting for care their conditions rarely improve, rather they end up needing more complex treatments and care. So as well as 'winter pressures' and the coronavirus, the pressure is also on to clear the backlogs.

This winter, however, the pressures are not only about dealing with demand on the front line. Behind the scenes, the health and care sector in England is preparing for what Sajid Javid told the Conservative Party Conference would be a year of 'fundamental and far-reaching' reform in 2022, much of which relates to health and social care integration.

The Health and Care Bill, which will put Integrated Care Systems (ICSs) on a statutory footing by April 2022, is passing through Parliament. In parallel, and somewhat unconventionally due to the timescales involved, a torrent of guidance is emerging which sets out the requirements for this timescale to be met. The fact that (at the time of writing) there have been 29 separate pieces of guidance, grouped into seven themes, gives an indication of the scale of the task – not to mention the required reading time!

Even further guidance is expected. The PM has indicated there will be a national implementation plan for integration before the year end. If one was being cynical, one could speculate that every good idea in Whitehall is being swept up and packaged into a not particularly well organised cascade of guidance in a well-meaning attempt to provide clarity. While some of this may be helpful, it all takes time to process, digest and translate to the individual circumstances of each area and act upon.

Although putting ICSs on a statutory footing is perhaps not wholescale structural reform, it does involve a significant shuffling of deckchairs. Aspects of which include: the establishment of the Board (ICB) and wider Partnership (ICP) and how they will operate, how place-based partnerships and provider collaboratives will function, the transition of functions and people from CCGs to the ICB, changes to the financial framework , what proportionate governance arrangements might look like and changes to digital systems and data sharing. And all this just to get to the starting line of 1 April 2022. Beyond this, the new arrangements will need to embed and evolve over time.

Will the bill solve the problems of integration? This is the burning question! I have attended many events over the last few months where this has been the topic of much discussion. The language being used by government is certainly reassuring, with a focus on prevention, addressing inequalities and the wider determinants of health and wellbeing. There appears to be a greater recognition of the essential role of local government, and the need for this to be based on equal partnership (perhaps learning the lessons of sustainability and transformation partnerships?) and a greater recognition of the importance of place.

All this is welcome – but there is a feeling that, by and large, the proposals are still too focused on integration within the NHS itself, meaning the risk of damaging those all-important cross-sector relationships remains.

The bill does make progress in removing some perverse incentives, particularly within the NHS, which have acted as hurdles along the path to integration. It strips away much of the competition inherent in the 2012 Act. Parallel changes to the payment and contracting system are aimed at better supporting integration and shifting resources around the system more appropriately, in comparison to the prior 'payment by activity' approach in the acute sector.

The general consensus seems to be that whilst the bill does not break down all the barriers, it does provide a basis on which to move forward, and perhaps an impetus for those areas where cross-sector collaboration and relationships are not as advanced. These and other issues are explored in more depth in our joint briefing with HFMA: The future financial sustainability of health and social care.

Of course, there is one key factor that could act as a fly in the integration ointment. The now urgent need for social care to be appropriately and sustainably funded. The government's recent announcement of the Health and Social Care Levy, a cap on care costs and expansion of the means-test thresholds have been presented almost as a fait accompli in this regard. Although these reforms are a helpful step in addressing the costs to individuals, they do nothing to help alleviate the pressures on local government and the provider sector – in fact they increase the cost to the public purse.

The government's policy makes it clear that these pressures must continue to be met from existing short-term funding measures such as council tax and efficiencies, passing the buck to local government and the taxpayer. Again, this is discussed in more depth in our recent article, A first step along the road to reform.

Without adequate funding and long-term certainty to enable good public financial management the social care sector will struggle to meet current demand, never mind have the bandwidth to invest in the transformation required to enable integration and prevention. The forthcoming spending review, and the commitment to a white paper on social care reform before the year end, provides the opportunity for the government to address the sustainability of the social care sector in a holistic manner. To finally grasp the nettle and decide what sort of social care system we want for our most vulnerable, and to appropriately fund it – now and for future generations.

Another area which looms large (although perhaps not quite large enough) in the integration conversation, and which has recently undergone significant change at national level, is public health. Centrally, the newly formed Office for Health Improvement and Disparities sets a clear intention to address health inequalities and improve prevention to reduce the pressure on the health and care system.

The experience of the pandemic has highlighted the essential role of public health at the local level. Yet this has experienced significant underinvestment, with almost a 25% real terms reduction to the public health grant in recent years. This seems to run contrary to the policy rhetoric around a focus on prevention, addressing health inequalities and levelling up, and again risks those all-important relationships with local government required for successful integration.

The word 'relationships' is a dominant feature of any discussion on integration – and those relationships are dependent on leadership. The tone set from the top on cross-sector collaboration and shared goals sets the scene for the entire organisation's approach to better understanding and collaboration across organisational boundaries. The Department for Health and Social Care has recognised this, recently launching a review of leadership in health and care. Unfortunately for integration, there is an element of horses and stable doors here, as ICS Chairs and CEOs are in the process of being appointed.

The review aims to "foster and replicate the best examples of leadership" to ensure that "every pound of investment is well spent." From the experience of the events I have attended, I suggest they look to the finance profession to find such exemplars. Not only is the finance profession key to support, enable and drive the changes required, the optimism and passion to do the right thing for their populations is truly inspirational and must be harnessed, rather than stifled by legislation, policy and funding.

So, winter is coming and it will certainly be busy, on the front lines and behind the scenes. While the seasonal cheer may have shadows looming over it, the government could certainly take the opportunity that the spending review brings and make it more festive for those in health and care, by ensuring that the entire sector has the funding and certainty it so badly needs. Surely a clear vision of further reforms to come in 2022 and beyond isn't too much to ask for Christmas?

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