Applies to England
Purpose of guidance
This is guidance for integrated care partnerships on the preparation of integrated care strategies. This document contains an introduction, 2 sections of statutory guidance on the preparation of the integrated care strategy including involvement and content, and a section of non-statutory guidance relating to the publication and review of the integrated care strategy.
In preparing an integrated care strategy, an integrated care partnership must have regard to any guidance issued by the Secretary of State,[footnote 1] this includes the 2 sections of statutory guidance within this document.
Case studies have been included to demonstrated and share some of the innovative approaches taking place throughout England.
Throughout England considerable work on integration has already taken place, including through health and wellbeing boards, the preparation of Better Care Fund plans, or the previous non-statutory integrated care systems (prior to the Health and Care Act 2022) to develop strategies that support more integrated approaches to delivering health and care. The integrated care strategy should build on that existing work and momentum to further the transformative change needed to tackle challenges such as reducing disparities in health and social care; improving quality and performance; preventing mental and physical ill health; maximising independence and preventing care needs, by promoting control, choice and flexibility in how people receive care and support.
The integrated care strategy should set the direction of the system across the area of the integrated care board and integrated care partnership, setting out how commissioners in the NHS and local authorities, working with providers and other partners, can deliver more joined-up, preventative, and person-centred care for their whole population, across the course of their life. The integrated care strategy presents an opportunity to do things differently to before, such as reaching beyond ‘traditional’ health and social care services to consider the wider determinants of health or joining-up health, social care and wider services.
The development of the integrated care strategy can be used to agree the steps that partners, working closely with local people and communities, will take together to deliver system-level, evidence-based priorities in the short-, medium- and long-term. These priorities should drive a unified focus on the challenges and opportunities to improve health and wellbeing of people and communities throughout the area of the integrated care partnership. These can include how areas will contribute to the ambitions to reduce geographic disparities in wellbeing and healthy life expectancy, and overall increase them as set out in Levelling up the United Kingdom (2022). It can also include how areas will put personalised care and support at the heart of adult social care, and help everyone to access outstanding quality care that supports choice, control and independent living as set out in People at the heart of care (2021).
The Health and Care Act 2022 amends the Local Government and Public Involvement in Health Act 2007, and requires integrated care partnerships to write an integrated care strategy to set out how the assessed needs (from the joint strategic needs assessments, see glossary in annex B) can be met through the exercise of the functions of the integrated care board, partner local authorities (see glossary in annex B) or NHS England (NHSE). This guidance is focussed on the integrated care strategy and does not include all of the benefits we expect integrated care partnerships to bring to health and social care, such as their role in convening partners to facilitate cooperation and integration. Our previously published engagement documents include some of those benefits: Integrated care partnerships (ICP) engagement document: integrated care systems (ICS) implementation (2021) and Integrated care partnerships (ICP): engagement summary (2022).
This guidance seeks to aid systems in their preparation of their integrated care strategies, but during this transition year, we recognise that the time available to develop initial integrated care strategies will be shorter than desired. We recognise that this may limit the breadth and depth of the initial integrated care strategy. We expect that the integrated care strategy will mature and develop over time. Additionally, this guidance reflects a new process, carried out by a new joint committee, so we recognise that guidance might not address all matters perfectly. We would welcome any feedback or comment on this guidance, as we intend to review, and if necessary, refresh this guidance by June 2023.
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Integrated care partnerships and the wider system
The make-up of the integrated care partnership
The Health and Care Act 2022 establishes integrated care boards and requires them, with partner local authorities, to form a joint committee: the integrated care partnership. The integrated care partnership may appoint additional members and determine its own procedures including the processes for agreeing the integrated care strategy.
This figure shows the integrated care partnership and its constituent organisations at ‘system’ level (the area of the integrated care board and integrated care partnership). The membership of the integrated care partnership includes, at a minimum, one representative from the integrated care board and one from each partner local authority. The partnership may appoint additional members. In some cases partner local authorities might be involved in more than one integrated care partnerships (not shown on diagram).
The purpose of the integrated care strategy
The integrated care strategy is an opportunity to work with a wide range of people, communities and organisations to develop evidence-based system-wide priorities that will improve the public’s health and wellbeing and reduce disparities. The integrated care strategy must set out how the assessed needs (identified in the joint strategic needs assessments) of the integrated care board and integrated care partnership’s area are to be met by the exercise of functions by the integrated care board, partner local authorities, and NHSE (when commissioning in that area). These commissioners must have regard to the relevant integrated care strategy when exercising any of their functions, so far as relevant. With respect to NHSE, this only applies when they are exercising any functions in arranging for the provision of health services in relation to the area of a partner local authority. This includes their commissioning functions, plans and strategies (including the integrated care board and Partner NHS trusts and NHS foundation trusts 5-year joint forward plan) and working with their system partners. When the integrated care partnership receives a new joint strategic needs assessment, from a health and wellbeing board, it must consider refreshing the integrated care strategy.
The process of developing an integrated care strategy is itself an opportunity for partners to work together, including those who have not always historically been directly involved in developing health and wellbeing strategies, such as, but not limited to, social care providers. Once a strategy is published, integrated care partnerships should continue to consider how it is implemented. The strategy could include key strategic priorities for system-level action, to tackle the needs identified in the joint strategic needs assessments, complementing what is already being done at ‘place’ (see glossary in annex B). This is not about taking action on everything at once, nor should the key strategic priorities for system-level action be overly prescriptive on what is occurring locally, for example in health and wellbeing boards. It should aim to build upon previous system-level plans and strategies.
The Care Quality Commission’s reviews will assess how the integrated care strategy is used to inform the commissioning and provision of quality and safe services across all partners, within the integrated care system, and that this is a credible strategy for its population. This could include, for example, the equal partnership between the integrated care board and the integrated care partnership.
Health and wellbeing boards and subsidiarity
The health and wellbeing board (see glossary in annex B) remains responsible for producing both the joint strategic needs assessment and the joint local health and wellbeing strategy (they will be required to consider revising the joint local health and wellbeing strategy on receiving a new integrated care strategy). The integrated care strategy should complement the production of these local strategies. It should identify where needs could be better addressed at integrated care system level and bring learning from across places and the system to drive improvement and innovation, for example challenges that could be met by integrating the workforce or considering population health and care needs and services over this larger area. It should not replace or supersede the joint local health and wellbeing strategies, which will continue to have a vital role at place.
For many integrated care partnerships there will be multiple health and wellbeing boards in their area, and there could be multiple joint strategic needs assessments and joint local health and wellbeing strategies (and in some cases a health and wellbeing board will be part of multiple integrated care partnerships). Integrated care partnerships should ensure that the integrated care strategy facilitates subsidiarity in decision making, ensuring that it only addresses priorities that are best managed at system-level, and not replace or supersede the priorities that are best done locally through the joint local health and wellbeing strategies. The integrated care partnership should ensure that it builds the principle of subsidiarity in the system, encouraging partners to reflect on whether decisions and delivery are happening at the right level when they produce the strategy.
For a few integrated care partnerships, there will be just one joint local health and wellbeing strategy in their area. It is up to the health and wellbeing board and integrated care partnership to determine how the joint local health and wellbeing strategy and the integrated care strategy will complement each other and ensure that the assessed needs are addressed between them. For example, the integrated care strategy could focus on integration with health-related services, sharing best practice and encouraging innovation across the system, bringing a wide set of data or evidence from research and practice to complement the joint strategic needs assessment or on issues that span multiple integrated care partnerships such as the provision of ambulance or specialist services.
Legal requirements and definition of terms
Definitions of terms
Where ‘must’ is used, this indicates that there is a statutory requirement. ‘May’ indicates that action could be taken, but it is not a requirement to do so. Where ‘should’ is used it indicates that something is not a legal requirement, however, note the section on ‘Legal duties and powers of the integrated care partnership’ which is relevant to the statutory components of this guidance.
Annex B contains a glossary of terms commonly used in this document.
Legal duties and powers of the integrated care partnership
In preparing the integrated care strategy each integrated care partnership must have regard to guidance issued by the Secretary of State (including this guidance or future guidance on the preparation of the integrated care strategy). Alongside this requirement, integrated care partnerships, when preparing an integrated care strategy must also consider the areas set out in the following table, cross-referenced to the appropriate points in the guidance.
Legal duties and powers - where to find more information in this guidance
|Statutory requirements||Further detail in this guidance|
|The integrated care strategy must set out how the ‘assessed needs’ from the joint strategic needs assessments in relation to its area are to be met by the functions of integrated care boards for its area, NHSE, or partner local authorities.||See ‘Evidence of need and the integrated care strategy’ for detail on evidence of need. See ‘Content of the integrated care strategy’ for a non-exhaustive selection of topics for the integrated care partnership to consider, including: shared outcomes; quality improvement, joint working and section 75 of the NHS Act 2006; personalised care; disparities in health and social care; population health and prevention; health protection; babies, children, young people, and their families, and health ageing; workforce; research and innovation; ‘health-related services’; data and information sharing.|
|In preparing the integrated care strategy, the integrated care partnership must, in particular, consider whether the needs could be more effectively met with an arrangement under section 75 of the NHS Act 2006.||See ‘Joint working and Section 75 of the NHS Act 2006’ in this document for further detail on this requirement.|
|The integrated care partnership may include a statement on better integration of health or social care services with ‘health-related’ services in the integrated care strategy.||See ‘Health-related services’ in this document for further detail on this power.|
|The integrated care partnership must have regard to the NHS mandate in preparing the integrated care strategy.||See the section in this document on the ‘NHS mandate’ for further detail on this requirement.|
|The integrated care partnership must involve in the preparation of the integrated care strategy: local Healthwatch organisations whose areas coincide with, or fall wholly or partly within the integrated care partnership’s area; and people who live and work in the area.||See the section on ‘Involving people and organisations in the strategy’ for further detail on involving people and groups for the integrated care partnership to consider, including: local Healthwatch; people and communities; providers of health and social care services; the VCSE sector; local authority and integrated care board leaders; wider organisations; other partnerships and fora.|
|The integrated care partnership must publish the integrated care strategy and give a copy to each partner local authority and each integrated care board that is a partner to one of those local authorities.||See the section on ‘Publication and review’ for further detail on this requirement.|
|Integrated care partnerships must consider revising the integrated care strategy whenever they receive a joint strategic needs assessment.||See the section on ‘Publication and review’ for further detail on this requirement.|
The government sets objectives for NHSE through a statutory mandate. The integrated care partnership must have regard to the mandate, alongside the guidance from the Secretary of State, when preparing their integrated care strategy.
For integrated care partnerships, having regard to the mandate means following the mandate unless there are compelling or exceptional reasons not to do so. In practical terms, integrated care partnerships should ensure they act in accordance with the mandate, where its content is applicable to their context. The mandate will also be reflected in NHSE’s own strategic documents and planning guidance.
2022 to 2023 will be a transition period. We expect that integrated care partnerships will want to refresh and develop their integrated care strategy as they grow and mature. In order to influence the first 5-year joint forward plans which are to be published before the next financial year, the integrated care partnership would have to publish an initial strategy by December 2022. We recognise that integrated care partnerships are at different levels of maturity and development, and this will be reflected in the breadth and depth of the work that can be done in preparing the strategy and, subsequently, what is included in the initial strategy. Integrated care boards and NHS Trusts and Foundation Trusts must refresh their 5-year forward plan annually, and we expect integrated care partnerships to continue to develop and refine the integrated care strategy.
DHSC has committed to reviewing, and if necessary, refreshing this guidance in June 2023 following the first cycle of joint 5-year forward plans and integrated care strategies in 2022 to 2023.
Producing an integrated care strategy
Responsibility for developing the strategy
The integrated care partnership is responsible for preparing the integrated care strategy, so integrated care boards and partner local authorities should engage, cooperate and provide the necessary resources for the preparation for the strategy. Other partners that are appointed to the integrated care partnership should participate fully. The integrated care strategy is an opportunity to consider challenges in the short-, medium-, and long-term about how assessed needs can be met.
As part of establishing their procedures, integrated care partnerships should agree their processes for finalising and signing off the strategy. There is more information about the requirements relating to the publication of the strategy later on.
Evidence of need and the integrated care strategy
The integrated care strategy is intended to meet the needs of local people of all ages identified in the relevant health and wellbeing boards’ joint strategic needs assessments. These assessments relate to all health (physical and mental), and social care needs of the whole population. Integrated care partnerships should use these assessments to explore gaps in care, unwarranted variation, and disparities in health and care outcomes and experiences between parts of the population and understand opportunities where system wide action could be effective in improving these, including addressing the wider determinants of health and wellbeing, and preventing ill-health and future care and support needs.
However, integrated care partnerships should aim to go further, drawing on additional intelligence such as assessments of local communities and needs developed by providers; the perspectives of local communities, and evidence from research and practice to build on their understanding of health and care needs and further articulate how those needs can be met.
Groups who can be under-represented in assessments of need
While joint strategic needs assessments are useful to understand assessed needs, they will not always be able to offer a comprehensive overview of all population health and care needs, due to limitations in data and information. Some people, such as but not limited to unpaid carers, those in inclusion health groups (see the definition below) and others who face social exclusion can be systematically missed in data sources that feed into assessments because, for example, they are not registered to receive health services, or they or others do not recognise that they have a health or care need.
What is inclusion health?
‘Inclusion health’ describes action to improve health and care for people who are socially excluded, experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma) and stigma and discrimination. They are not consistently accounted for in electronic health databases, which makes them effectively ‘invisible’ in health and care needs assessments. These experiences frequently lead to barriers in access to healthcare and extremely poor health outcomes, contributing considerably to health disparities. Inclusion health groups typically include people experiencing homelessness, including people who sleep rough, vulnerable migrants, Gypsy, Roma, and Traveller communities and sex workers, as well as victims of modern slavery, people with drug and alcohol dependency and people in touch with the criminal justice system.
Paucity of data and other evidence can itself be a significant barrier to the provision of effective, integrated care. The integrated care strategy should identify opportunities for research where there are gaps in evidence either of health and care need or gaps in how those needs might be effectively met (see ‘Evidence of need and the integrated care strategy’). The Health and Care Act 2022, amends the National Health Service Act 2006 to require integrated care boards to have regard to the need to reduce inequalities between persons, not just patients, in respect to access to health services. The integrated care strategy should ensure that the needs of underserved populations are identified and met through the integrated care board, NHS England, or responsible local authorities exercising their functions.
Lancashire’s ‘Changing Futures’ programme
In Lancashire’s ‘Changing Futures’ programme new Enhanced Service Hubs are bringing together health, housing, substance misuse, adult social care and probation services at a local, system and service level around the person to improve support for people facing multiple disadvantage. The approach is led at a strategic level via the local integrated care system, helping to address local strategic barriers and close gaps in support across the whole county.
Involving people and organisations in the strategy
In the preparation of the integrated care strategy, integrated care partnerships must involve the people who live and work in the area covered by the integrated care partnership.
The process of engagement, and co-production with a wide range of people and organisations drawing on best practice and guidance will strengthen the strategy. Local authorities and NHS bodies have established arrangements for involving people and organisations and typically will have worked together for a number of years in developing this engagement. The integrated care partnership will want to build on this existing work and discuss how to plan and resource engagement across the system that makes sense to those being engaged.
Integrated care partnerships should explore which other local partners and stakeholders they will need to engage in the development of the integrated care strategy either directly or indirectly through other organisations. These will vary between areas. Annex A contains a non-exhaustive list of people and organisations that the integrated care partnership should consider engaging in the production of the integrated care strategy.
It will be, at times, more appropriate for the individuals or organisations to be involved directly at a local level in their neighbourhoods and communities rather than at the level of the integrated care partnership. The integrated care partnership should complement and champion this place-based and neighbourhood engagement and ensure that there are mechanisms for relevant local insights to inform the integrated care strategy. To ensure that any engagement is to have the greatest impact, the integrated care partnership should also ensure that involvement is at the right level of decision making. They should also consider the time and capability of partners to be involved, and how that is most effectively used.
Integrated care partnerships should also ensure that any engagement or involvement opportunities are accessible; locally available; allow for reasonable adjustments, and, where appropriate, provide resources and training to build capability and capacity to enable effective participation. The NHS England and DHSC Working in partnership with people and communities guidance contains effective strategies and techniques for engaging people and communities in the development of the integrated care strategy.
The integrated care partnership should also ensure that it is transparent about the process for preparing the strategy from the outset and be clear about those responsible for the strategy, including a publicly available contact details to ensure people and groups can pro-actively engage in the preparation of the strategy. The integrated care strategy is an opportunity to and set out expectations as to how people should be involved locally across the system.
Finally, we recognise that 2022 to 2023 is a transition year, and the level of engagement might need to vary, according to the time and resource available to engage people and organisations in in the preparation of the initial integrated care strategy. However, we do expect this engagement to increase as the integrated care partnerships mature, and integrated care strategies develop.
The next sections set out particular people, and organisations to be involved in the production of the integrated care strategy.
Surrey Heartlands integrated care system: an integrated approach to supporting carers
Surrey Heartlands integrated care system have worked closely with the local health and wellbeing board to develop a Carers Strategy 2021 to 2024 in partnership with carers that will improve carer identification, outcomes, experience and quality throughout the integrated care system. This system-wide, integrated approach to the strategy will set up a ‘carer friendly’ system to support all carers, regardless of background – for instance, identifying, young carers across the health and social care system in Surrey Heartlands, then assessing and satisfying their health and wellbeing needs.
Integrated care partnerships must involve local Healthwatch organisations in the production of the integrated care strategy. They can determine locally what form that involvement takes. Integrated care partnerships should involve Healthwatch at an early stage in the development of the strategies so they can assist in the development of the engagement approach and strategy.
This might be done individually with each Healthwatch or through a larger network, which many local Healthwatch organisations are forming. Local Healthwatch organisations could contribute in different ways to support the integrated care partnership through their statutory functions including:
- collating and sharing existing insight about people’s experience of health and care services
- undertaking additional research and engagement in support of development or delivery of the strategy to gather the views and experiences of local people, including those from marginalised groups who are seldom heard
- providing advice and expertise to support the integrated care partnership to undertake and commission community engagement to a high standard
- supporting the integrated care partnership to collaborate with people with lived experience of inequality to carry out monitoring processes
People and communities
Integrated care partnerships should consider how a wide range of people are able to engage and input into the production of this strategy. This could include, but is not limited to pro-actively involving people with a range of lived experiences of accessing health and or social care services or having a mental or physical health condition; seldom heard voices, people experiencing, or at risk of, homelessness; those who commissioners have a responsibility for, but reside outside of the area of the integrated care board and integrated care partnership, such as people providing unpaid care at a distance; or those receiving specialist services outside the integrated care partnership area. Additionally, integrated care partnerships should ensure that this engagement is inclusive of children, young people and their families (including new and expectant parents).
This engagement should include facilitating the involvement of people who might face additional challenges such as severe mental illness, learning disabilities, or those who face digital exclusion. This should include consideration of people, and organisations who both formally and informally advocate on behalf of people who cannot otherwise easily engage. This engagement should be achieved through involvement and co-production, in the preparation of the integrated care strategy. To achieve this, integrated care partnerships should draw upon local experience, for example from local government, providers or voluntary, community, and social enterprise groups to support this engagement. These organisations, like Healthwatch organisations will have existing co-production and citizen engagement mechanisms which integrated care partnerships can use and build upon.
The Health and Care Act 2022 amends the National Health Service Act 2006 to require integrated care boards to promote the involvement of patients, carers and their representatives in the exercise of their functions when it relates to the prevention or diagnosis of illness in patients or their care and treatment and ensure that they are involved in the planning, development and operation of commissioning arrangements.[footnote 2] Integrated care partnerships should also promote this involvement in the development of the integrated care strategy, and consider how the strategy supports personalised care and support (see ‘Personalised Care’).
Providers of health and social care services
Providers of adult and children’s social care, primary care (including general practice, pharmacy, eye care, dental and audiology services), community health services, secondary care, and public health services will have important insights into how the needs of local people can be met due to their knowledge, experience and direct links with people who draw on health and social care. The integrated care partnership should map out the different types of providers and practitioners who should be engaged in the development of their initial strategy and then who will be involved in the further development and refresh of the strategy. This mapping should be inclusive of voluntary, community, and social enterprise (VCSE) and independent sector providers. In larger systems, it might be necessary for each place to gather this information and share it upwards with the integrated care partnership to ensure full coverage. We have listed examples of these types of service in annex A.
Integrated care partnerships should gather input from providers, including through place-based and neighbourhood-level areas. This input should come from a broad spectrum of health and care providers as strategic partners in the preparation of the integrated care strategy. Integrated care partnerships should recognise that the adult social care provider landscape, in particular, contains a diverse range and type providers, many of which are small to medium-sized enterprises, that will be closely tied to the communities they serve and will have important insights to inform the integrated care strategy. The integrated care partnership should take into account that these providers will face competing priorities and have differing capacities, and resources to engage in its activities. Nonetheless, the integrated care partnership should engage a diversity of perspectives in the strategy, and not assume that the commissioners are adequate proxies for the provider voice. For example, for adult social care providers, integrated care partnerships could draw on care associations or similar local, regional or national networks, such as registered managers and individuals networks. When engaging with adult social care providers, the integrated care partnership should use the guidance on the expected ways of working for integrated care partnerships and adult social care providers to ensure that they are appropriately engaged in the development of the integrated care strategy.
Integrated care partnerships should ensure communications and involvement are appropriate to the providers, make clear the value and purpose of their involvement and the ways in which the development of the integrated care strategy is relevant for them, and how their perspectives and expertise will be used. Conversely, some providers span multiple integrated care partnerships. In such cases, integrated care partnerships should consider working together to facilitate this engagement.
Greater Manchester Oral Health Sustainability and Transformation Programme
The Greater Manchester Health and Social Care Partnership funded a 3-year £1.5 million Oral Health Sustainability and Transformation Programme, targeting the 4 localities within Greater Manchester with the poorest oral health in children. The programme included daily supervised fluoride toothbrushing programmes in all early years settings, and universal distribution of free fluoride toothbrushing packs and oral health advice by health visitors. It also fostered links between health visiting teams and dental practices to encourage early dental attendance. This system-level approach to oral health was informed by strong evidence of cost effectiveness and was well integrated into early years provision. Some of the main benefits include reductions in primary and secondary care service use.
When engaging with primary care providers to develop the integrated care strategy, the integrated care partnership could consider whether appropriate to engage with any primary care forums or networks established at system level that represent a breadth of views across primary care, as well as drawing on primary care expertise on place-based boards.
Sheffield primary care mental health transformation
A collaboration between Sheffield Health and Social Care NHS Trust, Primary Care Sheffield, NHS Sheffield Clinical Commissioning Group, Sheffield City Council, Sheffield Mind and Rethink Mental Illness has created a responsive mental health service that has helped to reduce mental health inequalities and delivered person-centred care closer to home. These organisations came together with a pooled transformation budget to develop the primary care and mental health transformation programme. They adopted a novel approach to bring care closer to home, allowing the project to work closer with communities and tap into unmet demand. As a result, in some of the PCNs they doubled the mental health access rate for minority ethnic groups presenting to secondary care, increasing from 11.6% to 22%.
As well as involving providers, the integrated care partnership should involve clinical and care professionals, including those working on the front-line in health and social care as they will have important expertise on how services can be constructed and successfully delivered. To achieve this, they can work through the existing infrastructure that supports clinical and care leadership, to help ensure the widest possible range of clinical and social care leaders are able to contribute.
Voluntary, community, and social enterprise (VCSE) sector
The voluntary, community, and social enterprise sector (VCSE) covers a wide variety of organisations with an equally wide range of experience and insights.
There are a wide range of VCSE organisations that each fulfil a variety of roles including, but not limited to, organisations led by people with lived experience, service providers (including for social prescribing provision), advice and advocacy services, funders of research; tackling disparities in health and care and influencing the wider determinants of health.
VCSE alliances, or similar entities, are present in each area, and will be important in the production of the integrated care strategy. Integrated care partnerships should also consider the different roles VCSE organisations can play and involve them when relevant, for example, when involving people and communities or providers.
Connections over coffee
NHS Devon has a buddying scheme where 16 leaders from the voluntary and community sector link with 16 leaders from the wider system including the CCG, local authorities and NHS Trusts. They spend 12 months getting to know each other through 6 weekly phone calls or cups of tea and learn how their role fits into the overall care picture for Devon. It has facilitated those vital connections that help to reduce the invisible barrier that sometimes occurs between sectors.
Local authority and integrated care board leaders
Integrated care partnerships should involve chairs of health and wellbeing boards, local authority directors of children’s services, adult social services, and public health and their teams in the production of the integrated care strategy. Whilst the individuals holding these roles are not statutory members of the integrated care partnership, they are statutory members of health and wellbeing boards, and will be involved in the development of joint local health and wellbeing strategies. This gives them an important role in ensuring coherence across these documents.
These directors and their teams also have multiple roles within integrated care systems, including as leaders at place, in supporting system aims and in helping to inform fulfilment of other legal duties. Integrated care partnerships should draw on their expertise and guidance, and involve them when considering other sources of relevant expertise, when preparing the integrated care strategy. In particular, directors of public health and their teams can provide expertise and guidance on how system partners can work together to improve health and care outcomes and experiences across the whole population.
Integrated care partnerships should engage Integrated care board leads for areas including people, workforce and digital and data, children and young people and those with delegated responsibility for statutory duties relating to children and young people with special educational needs and disabilities and child safeguarding.
Engaging integrated care board leads with responsibilities related to children and young people, combined with directors of public health and directors of children’s services, will ensure that local children’s leadership have an opportunity to ensure the strategy meets the assessed needs of babies, children and young people and their families.
While engagement with these individuals is important, it should not be seen as a proxy for the involvement of relevant providers, people who use services, or the wider workforce.
The integrated care strategy may include a statement on integration with other services that impact upon peoples’ health and wellbeing but are not health and care services. Examples will include employment support, housing and homelessness services and leisure services (see ‘Health-related services’ for more information).
Integrated care partnerships should involve representatives from these other services, and those who commission these services, in the production of the integrated care strategy to understand how these services can be better integrated with health and care services to achieve joined-up, person-centred care and preventative interventions for their population. This should be inclusive of those providers in the VCSE or independent sector.
In two-tier local authorities, district councils should be closely involved in the preparation of integrated care strategies – because they have a range of strategic and delivery responsibilities for services including housing, homelessness services, planning and spatial development, and leisure services.
Furthermore, other groups such as businesses, employers, housing providers (particularly registered providers of social housing) and local planning services play a critical role in supporting the health and wellbeing of the local community. Engaging, and involving with them can identify new opportunities and innovative ways to improve population health.
Improving population health programme in West Yorkshire
West Yorkshire Health and Care Partnership’s ‘Improving Population Health Programme’ has an established partnership with the West Yorkshire Violence Reduction Unit since 2019. Working with public sector institutions and communities to help prevent and reduce violence with a particular focus on adversity, trauma, resilience, early intervention, education and partnership working. This programme brings together specialists from all sectors, including; health, law enforcement, local government, education, voluntary and community services and others to understand and tackle the root causes of violent crime, trauma and adversity.
Other partnerships and fora
There will be a range of other partnerships and fora that operate at a system or regional level. Integrated care partnerships should, where possible, engage with these existing partnerships and fora rather than duplicate their work. It could also be appropriate for integrated care partnerships to involve those partnerships in the preparation of the integrated care strategy, and for the integrated care partnership to be involved in the creation of other partnerships’ strategies and plans.
Content of the integrated care strategy
The content and format of the integrated care strategy will vary from system to system. However, the strategy presents an opportunity to consider challenges, and solutions, across the short-, medium-, and long-term. The following section contains some of the areas the integrated care partnership should consider.
Approaches and mechanisms
Agreement by all actors within the integrated care system on priority outcomes, based on the needs identified in the joint strategic needs assessments, is a powerful way for the integrated care strategy to bring focus to the system, galvanising joint working and driving progress on the most important outcomes for the local population. We expect this to be an important aspect of all integrated care strategies, which can also play an important role in supporting the setting of joint goals for local areas.
The Department of Health and Social Care will set out further detail on shared outcomes, as described in ‘Health and social care integration: joining up care for people, places and population’, by April 2023. This will consider the relationship of this work to integrated care strategies.
Integrated care partnerships should consider how they can meet assessed needs, together with how they can secure continuous and sustainable improvement in care quality and outcomes when preparing the integrated care strategy. The National Quality Board (NQB) has issued guidance and other documents to support using quality improvement to achieve this.
Joint working and section 75 of the National Health Service Act 2006
The integrated care partnership must consider whether needs could be better met through an arrangement, such as the pooling of budgets, under section 75 of the NHS Act 2006 (see box). Section 75 is a key tool to enable integration and integrated care partnerships should consider the benefits of section 75 arrangements as part of preparing their integrated care strategies. However, Individual section 75 agreements remain the responsibility of the partners involved.
Section 75 of the National Health Service Act 2006 and the Better Care Fund
This is a long-standing mechanism to allow one or more NHS body (for example NHS England, an NHS Trust or NHS Foundation Trust, or an integrated care board) to work in partnership with one or more local or combined authorities. These partnerships can include the delegation or joint exercise of prescribed (in regulations) functions, the pooling of budgets, and the formation of joint committees. Section 75 is also the legal mechanism that underpins the Better Care Fund (BCF). BCF plans are jointly agreed by integrated care boards and Local Authorities and signed off by local health and wellbeing boards. BCF plans, including narrative plans, include agreement on how these bodies will deliver integrated health and social care services and how a locally pooled fund will be used to support this. BCF plans should be considered by the integrated care partnership.
As well as formal joint working mechanisms there are a range of other approaches that facilitate joint working, for example joint appointments between partners, better data sharing, the co-location of services, integrated teams, joint strategies and plans, or aligning budgets, The integrated care partnership could consider these in the production of the integrated care strategy.
The Department of Health and Social Care is intending to publish guidance on the scope of pooled and aligned budgets in Spring 2023 (as discussed in Health and social care integration: joining up care for people, places and populations (2022).
Areas to consider in the integrated care strategy
Further integration provides an opportunity to enhance personalisation, choice and flexibility for people who draw on health and adult social care services, and the people that provide them. Integrated care partnerships should set out how they can support the delivery of personalised care that enhances quality of life and promotes independence across health and social care. This should identify solutions to enable services to join up around the individual holistically, so that their care is tailored to them to meet their current and future needs.
The integrated care strategy could consider how specific types of support can enhance integration of services, such as the role that personalised advice can play in helping people to navigate the system; the use of self-directed support or highlighting ways of enhancing personalisation of care such as exploring new technologies and innovative models of care that can support a highly integrated and personalised experience of care, and pro-actively identify areas for improvement.
Disparities in health and social care
The integrated care partnership should set out how to address unwarranted variations in population health, and disparities in access, outcomes, and experience of health and social care across their population throughout their integrated care strategy. Integrated care boards have duties as to reducing inequalities in access to, and outcomes from, health services. The outcomes achieved also includes patient experience.[footnote 3] Constituent organisations of the integrated care partnership that are public bodies are subject to the Public Sector Equality Duty.[footnote 4]
Integrated care partnerships should consider how their integrated care strategy will address unwarranted variation in population health and disparities health and wellbeing outcomes, access, and experience. This should also address the drivers of these variations and disparities. In addition, certain groups, such as inclusion health groups or people with trauma from violence or abuse (including domestic abuse. See Domestic Abuse: statutory guidance (2022), can face multiple disadvantage and strategies could include a focus on what can be done for those experiencing significant, and multiple disadvantage.
Increasing access to health services in Hertfordshire
To increase access to health services by inclusion health groups, a Hertfordshire GP practice is providing drop-in clinics and community support with a multidisciplinary ‘complex needs team’ in partnership with local authorities and local voluntary, community, and social enterprise partners. They build trust and confidence with people who haven’t been reached before by making it clear that identification or proof of address is not needed for registration and any details shared are confidential, supporting socially excluded people to register. Community navigators help people access wider community support services to meet their needs, such as local physical and mental health initiatives, welfare, housing and education.
Population health and prevention
In preparing their integrated care strategy, integrated care partnerships should consider how to improve health and wellbeing and how to support prevention of physical and mental ill-health, future care and support needs, the loss of independence and premature mortality (see box for definition).
Definition of prevention
There is no single definition for what constitutes preventative activity, and this can range from wide-scale whole-population measures aimed at promoting health and wellbeing, to more targeted, individual interventions aimed at improving skills or functioning for one person or a particular group or lessening the impact of caring on a carer’s health and wellbeing. There are 3 categories of prevention activity, all of which are essential:
- primary prevention: population-wide interventions to promote wellbeing or prevent disease or ill-health before it occurs for example smoking cessation, social prescribing; reducing loneliness or isolation
- secondary prevention: early intervention that slows down or reduces any further deterioration including through detection of early disease and preventing disease progression, reoccurrence or relapse by reducing the impact of a disease that has already occurred (including screening), for example home adaptations, cancer screening, and addiction services
- tertiary prevention: formal intervention aimed at managing or reducing the impact of lasting illness or injury for example chronic disease management programmes / services, rehabilitations and reablement or supporting their carers
Definition of population health management
Evidence-based, pro-active, data-driven population health management techniques such as targeted predictive prevention and tackle long term challenges through addressing the wider determinants of health are an important part of the broader task of improving population health. Integrated care partnerships, when considering how they can address health and social care needs, should consider whether population health management approaches could support people in staying healthy, avoid illness, and the impact this can have on their and their families’ lives.
Patients with chronic conditions offered personalised care through population health management
Valens Primary Care Network, part of North East and North Cumbria integrated care system, set up a public health management approach to identify patients at high risk of becoming unwell due to both chronic physical health problems and depression. This was to start proactive, personalised support to improve their health and wellbeing. They set up a working group of health and care professionals including a public health consultant, GPs, a social prescribing link worker and the clinical commissioning group’s Medical Director to analyse the GP surgeries’ SystmOne database and identify people likely to be at high risk of becoming unwell.
Those who met the criteria were proactively contacted by a social prescribing link worker to ask if there were any environmental factors making it more difficult to manage their conditions.
Integrated care partnerships should ensure the full utilisation of public health expertise and leadership, centring on the local directors of public health. The strategy should include measures to improve health and wellbeing outcomes and experiences across the whole population, including addressing the wider determinants of health and wellbeing. This should include consideration of opportunities to work jointly and use collective resources, particularly where commissioning responsibility is shared between partners, to enable a system-wide approach, including to pursue improved healthy life expectancy and reduced health disparities (see ‘Disparities in health and care’ section).
Hospital discharge at Barnsley Hospital NHS Foundation Trust
Barnsley Hospital NHS Foundation Trust, working collaboratively with community partners, has implemented a permanent sustainable model for their hospital discharge services. The Barnsley Intermediate Care Pathway has embedded integrated working across the system with emphasis on multi-disciplinary, multi-agency collaboration to ensure timely access to rehabilitation or reablement as well as redeployment of occupational therapists to work within the community rather than in hospital, with social workers and therapists supporting joint assessments in people’s homes.
The model has so far resulted in the number of people leaving the service with no long-term care needs increasing from 19% in early 2020 to 50% on a consistent basis from April 2021.
Integrated care strategies should explore the role that local government, NHS, other large employers, providers and partners can play as anchor institutions (see the glossary in annex B for a definition), and the potential to use their spending power and significant assets to benefit communities and enhance socio-economic conditions.
Integrated care partnerships should consider evidence-based prevention measures in the integrated care strategy to: prevent and reduce mental and physical ill health and their risk factors; hospitalisation and rehospitalisation; the loss of independence; avoidable and premature mortality; long-term ill-health; and future care and support needs. This requires early identification of risk factors and illness and acting early to reduce their impact on individuals once identified.
Preventative action takes many forms including the commissioning of prevention services, the promotion of health and wellbeing, population health management, intermediate care services, measures to prevent harm, suicide, violence and abuse, including through the safeguarding, of adults and children; and adopting a broad-based approach which includes action on social and economic drivers of health and wellbeing.
Tobacco treatment and prevention in Humber and North Yorkshire integrated care system
Tobacco treatment and prevention is the number one prevention priority for Humber and North Yorkshire integrated care system. To do this the integrated care system set up a multi-agency tobacco steering group chaired by a Consultant in Public Health, which explored and then presented options for implementation of the long-term plan to the Board. Once the board agreed the way forward, the steering group became the Programme Board and refocussed on delivery. The integrated care system appointed a programme manager to coordinate and lead the group and ensure coherence across the system and has invested in a communications campaign to increase the likelihood that people who attend hospital are aware that sites are Smokefree and that help is available and will be offered.
Integrated care strategies should also consider using a ‘life course’ approach by considering the critical stages such as conception through to early years, transitions between life phases, or settings where large differences can be made in promoting or restoring health and wellbeing, and closing the disparities in health and wellbeing.
Integrated care partnerships should consider health protection in their integrated care strategy, with system partners including UKHSA, local authorities and the NHS who, among other bodies, having health protection responsibilities to deliver improved outcomes for the population and communities served. Health protection includes:
- infection and prevention control (IPC) arrangements within health and social care settings
- tackling antimicrobial resistance
- reducing vaccine-preventable diseases through immunisation
- prevention activities related to health protection hazards such as needle exchanges for blood-borne viruses (BBVs)
- commissioning of services for response to health protection hazards (such as testing, vaccination and prophylaxis) and to tackle health protection priorities (such as tuberculosis or BBV services)
- emergency preparedness, resilience and response (EPRR) across all hazards
- other health threats determined as priorities
Babies, children, young people, their families and healthy ageing
Partnership working in Doncaster to support children and young people’s mental health
The Doncaster Children’s Partnership set up the multi-agency Social and Emotional Mental Health (SEMH) Group, which brings together key influencers and decision-makers from the Clinical Commissioning Group, local authority, children and young people’s mental health service provider and other partners including the police. The SEMH promotes better joint assessments, planning and service delivery for vulnerable young people in need of care, which has led to reduced delays and improved access to appropriate help and support for children and young people in the local area.
People’s health and social care needs change over their lifetime, and integrated care partnerships must produce an integrated care strategy that relates to the needs of the whole population of their area including those of different ages.
When producing the integrated care strategy, the integrated care partnership should consider how the needs and health and wellbeing outcomes of babies, children, young people and families can be met and improved. These outcomes are shared by many partners, and the strategy should consider the integration of children’s services and, for example, whether joint commissioning and the pooling of funding under section 75 of the NHS Act 2006 would meet their needs more effectively. Family hubs, where appropriate, should be considered as an opportunity to integrate with wider health-related services.
What are family hubs?
Family hubs are a way of joining up locally and bringing existing family services together to improve access, connections between families, professionals, services, and providers, and putting relationships at the heart of family support. The Family hub model brings together services for families with children of all ages (0-19) or up to 25 with special educational needs and disabilities (SEND), with a ‘Start for Life offer’ at its core.
For more information, see the Family Hub Model Framework and resources provided by the National Centre for Family Hubs.
The integrated care strategy could take a whole-family approach, recognising that children’s and their parents’ and siblings’ needs are inter-connected, and that co-ordination between children’s and adults’ services can support improved outcomes for the whole family. For example, considering, how the provision of adults’ services can have a knock-on impact on the health and wellbeing of children and young people, and vice-versa particularly if the young person is caring for a parent or other adult.
Integrated care partnerships should consider what action can be taken at system level to strengthen the multi-agency safeguarding of children. This should include identifying how partners could address cultural and technological barriers to the safe and appropriate sharing of information between professionals in different agencies for child safeguarding purposes. Members of the integrated care partnership, including the integrated care board and local authorities, have separate statutory duties as a safeguarding partner. The integrated care partnership could support local safeguarding work, but the safeguarding partners retain the statutory responsibilities for safeguarding children in their local area, as set out in Working Together to Safeguard Children (2018).
The integrated care strategy should also consider healthy ageing, recognising that older adults experience the largest burden of noncommunicable disease, including cancer, dementia, and cardiovascular disease. The integrated care partnership should consider when preparing their integrated care strategy how the needs and health and wellbeing outcomes of older adults can be prevented met and improved, including through mechanisms such as improved housing and technological solutions; and how unpaid carers can be supported in accessing services which will improve outcomes for those in their care and carers themselves.
Healthy Ageing also includes ensuring that everyone in later life can experience good physical health and mental wellbeing; financial security and independence; have a sense of meaning and purpose; social connectedness and better resilience. Integrated care strategies could address these through considering healthy ageing when addressing the wider determinants of health and wellbeing, or through the promotion of health and wellbeing, early intervention, or health screenings.
Integrated care partnerships could consider, when preparing the integrated care strategy, key transition points and continuity of care, including becoming a parent; transitioning from maternity to children’s services; moves from primary to secondary and further/higher education; transitioning from children’s social care to adult social care, or from children and young people’s health and mental health services to adult services; entering employment; leaving a secure setting and re-entering the community; and receiving adult social care for the first time.
Meeting the needs identified by the joint strategic needs assessments is contingent on effective system-wide coordination of the recruitment, planning, development and delivery of ‘one workforce’.[footnote 5] Integrated care partnerships should work with providers to build a workforce that can deliver new ways of working that meet population health and wellbeing needs and wrap care and support around the person. This should apply to the workforces that work across health and social care.
A system approach to apprenticeships in Staffordshire and Stoke on Trent
Staffordshire and Stoke on Trent integrated care system and partners, as part of their programme to increase the participation of young people from diverse and hard to reach backgrounds in health and care careers, created a rotational apprenticeships across different providers in the integrated care system. This gives young people a clearly defined vocational pathway from school into a registered profession that does not require them to participate in full time education after the age of 18 or pay university tuition fees.
Participants can work at their own pace to achieve qualifications over a number of years by pausing following the completion of the NVQ level 3 Health and Care Apprenticeship or go straight onto applying for TNA or Registered qualification places. Over the course of the programme, the team worked with different partners in the integrated care system – including acute, mental health and community trusts, primary care, the local skills council, local authorities – to agree a joint approach to developing people from the local communities to step into health and care careers through rotational apprenticeships, with all partners agreed to provide funding and support for apprenticeship placements.
This will allow apprentices to gain experience of working in a number of different settings and pathways, allowing them to work across a number of different health and care settings. As a result of this initiative, 40 apprentices have been recruited since the scheme was created with 72% of these remaining in health or social care or pursuing higher level qualifications.
To support this ambition, integrated care strategies should consider the next steps needed to create an integrated workforce across health and adult social care. This could include developing shared values and common standards;[footnote 6] developing new cross-system ways of working or working with local partners to explore opportunities for system-wide recruitment and deployment informed by joined-up workforce planning; talent management, and skills development.
Joined up careers in Derbyshire integrated care system
In Derbyshire integrated care system, the integrated care system workforce team worked with Joined Up Careers, along with the Department for Work and Pensions, Jobcentre Plus and Futures for Business, to boost recruitment to the Sector-based Work Academy Programme (SWAP). The programme, led by the local City Council, prepares and places new entrants into the health and social care sector in Derby and Derbyshire, particularly targeting support to increase the employment rate for individuals unemployed and or on Universal Credit who are disabled, people aged 50+, ethnic minorities (BAME) and women. As a result of this programme, A total of 299 participants signed onto the pathways into health and social care employment project, many of whom were previously unemployed or economically inactive.
NHS England guidance on Building strong integrated care systems everywhere: guidance on the integrated care system people function further sets out how integrated care boards can work with integrated care partnerships and wider partners to support the delivery of its 10 outcome-based functions, which integrated care partnerships could use to support the preparation of the integrated care strategies.
Research and innovation
Integrated care partnerships should include consideration of research and practice-based evidence in their integrated care strategy, either to address challenges for health and wellbeing boards in assessing need or to improve the understanding of how those needs can be effectively met through the use of evidence from research or from further research. Similarly, the adoption and spread of proven innovation, can be an effective way to address the population needs and reduce disparities in access, outcomes, and experience. For both research and innovation, integrated care partnerships should consider involving wider partners (a non-exhaustive list is included in annex A).
Some services will have a substantial impact on health and wellbeing but are not provided by a health or social care provider. Health-related services are defined for the purposes of the integrated care strategy as services that could have an effect on the health of individuals, but are not health services or social care services.[footnote 7] This includes those impacting on wider determinants, such as employment and housing. Integrated care strategies should encourage closer working between commissioners and providers of health-related services and health and social care services. The integrated care strategy may include a statement of its views on how ‘health-related’ services and health and social care services can be more closely integrated. A non-exhaustive set of examples for health-related services are in annex A.
Mental health support for children and young people in Milton Keynes
The Bridge, a primary care network in Milton Keynes, has created a programme with system partners to improve mental health support for children and young people. Taking a bottom-up approach, they worked with several local partners including the public health team, the parish council, local schools, and voluntary and community sector organisations. This included setting up ‘Talk for Sport’, an exercise-based therapy programme which provides 8 weekly gym sessions for young people aged 11 to 18 with low to moderate mental health issues. As a result of this, the post-course questionnaire found that 100% had reached the minimum recommended amount of exercise per week, 69% had improved their mental wellbeing and 76% made new friends.
For those who draw on care and support, the right housing arrangements can be critical to supporting independent living outside of residential and institutional settings. The development of integrated care strategies should therefore explore the opportunities by having a joined-up approach to the planning, commission and delivery of housing and services related to housing, when setting out how they will meet assessed needs.
Improving Access to Psychological Therapies service in Hackney and the City of London
In the London Borough of Hackney and the City of London, employment advisers (EAs) are embedded in the Talk Changes – Improving Access to Psychological Therapies (IAPT) service. They work alongside therapists to support people with depression and anxiety disorders. The EAs - who like their therapist colleagues are employed by Homerton Healthcare NHS Foundation Trust - enable the service to deliver combined employment support and psychological treatment to all IAPT clients who choose this offer. The EAs and therapists work together with clients to develop and deliver personalised plans to enable clients to improve their mental health, find work, return to work and stay in work.
Data and information sharing
In the integrated care strategy, the integrated care partnership should explore how data and information are shared safely and appropriately between system partners, and across systems, and how effectively health and care data is linked. The strategy could identify opportunities for improved safe and appropriate data and information sharing to meet assessed needs. This could include:
- developing the right digital and data infrastructure to combine and link data to improve direct care, build better analytics for population health management and enable and support research and innovation, including data relating to the wider determinants of health
- identifying opportunities to use workforce, financial and operational capacity data to improve productivity and support better use of scarce resources
- exploring opportunities to build data and digital capability among commissioners and providers to inform decision making; improving waiting list management or delivering more personalised and predictive care
- building public trust in the use of data by ensuring compliance with the common law duty of confidentiality and data protection obligations for the use and sharing of personal data and transparency and awareness about the use of personal and patient data – for both direct care and secondary health and care purposes – through information materials and sustained communications to people and communities
Publication and review
This section relates to the publication of the integrated care strategy. This section is not statutory guidance.
Under the Health and Care Act 2022, the integrated care partnership must give a copy of the integrated care strategy to each responsible local authority and the integrated care board and must publish the integrated care strategy. Each integrated care partnership will need to establish how this is done through their procedures. We expect integrated care partnerships to ensure, likely through their constituent organisations, that this strategy is readily available to people throughout the integrated care system through routes that are most meaningful to people, including those with accessibility needs and low levels of health and care literacy. It is important that the people, their communities, and organisations who have contributed to the strategy are able to see the impact of their contributions reflected in the strategy and, in turn, the effect of their contributions on the provision of services.
Refreshing the integrated care strategy
Whenever the integrated care partnership receives a new joint strategic needs assessment from a health and wellbeing board, it must consider whether the integrated care strategy needs to be revised. Where possible, we suggest that integrated care partnerships work with health and wellbeing boards, local authorities, and integrated care board to align the timelines of their strategies and assessments with the 5-year joint forward plan, which must be published in April each year, and with relevant local authority plans and strategies. Integrated care partnerships should also consider any changes in their wider context including new or changed policies or guidance when refreshing their Strategy. To be transparent and enable wide participation, integrated care partnerships should be clear with their partners and the community about their timing cycles and when outputs will be published.
Review and evaluation
When refreshing the integrated care strategy and as part of its ongoing role in the system we expect the integrated care partnership to consider whether the strategy is being delivered by the integrated care board, NHS England, and local authorities. This can include, if appropriate, identifying, and evaluating the impact that the strategy has had on commissioning and delivery decisions. Integrated care partnerships should consider this impact from multiple perspectives, including providers, local people and communities and those engaged in the production of the strategy.
Section 116ZB(3)(b) Local Government and Public Involvement in Health Act 2007↩
Sections14Z36 and14Z45 of the National Health Service Act 2006↩
Sections 14Z34 and 14Z35 of the National Health Service Act 2006↩
Section 149 of the Equality Act 2010↩
The ‘one workforce’, as set out in the NHSE ICS Design Framework and the NHSE ICS-people-function-August-2021.pdf">ICS people function guidance, is the totality of staff working in health and care across each ICS. It includes those employed by and working in NHS organisations (acute, mental health, community, and primary care), in social care, in the voluntary, community and social enterprise sector, as well as those employed by future ICBs.↩
This should, where relevant, include values and standards raised in: Leadership for a collaborative and inclusive future - GOV.UK (www.gov.uk), Next steps for integrating primary care: Fuller stocktake report - NHS England, Final report of the Ockenden review - GOV.UK (www.gov.uk), A review of the fit and proper person test (publishing.service.gov.uk)↩
 See section 116ZB(8)(c) of the Local Government and Public Involvement in Health Act 2007 which outlines that ‘health-related services’ has the same meaning as section 195 of the Health and Social Care Act 2012.↩