Policy paper

Health and Care Bill: integration measures

Updated 10 March 2022

This fact sheet explains how the government plans to promote integration across health and care and support joint working through Integrated Care Boards and Integrated Care Partnerships.

Background

COVID-19, and the experience of the system over the last few years, has demonstrated how important it is that health and care workers from different organisations are able to work together to deliver high quality care.

For example, in Dorset hundreds of older people living with frailty are being monitored through a ‘virtual ward’, which is helping to keep them out of hospital. Doctors, nurses, social care staff, physiotherapists and others discuss patients who are put on a rolling ‘virtual’ list each week if thought to be at risk of hospital admission. As well as discussing patients’ medical issues, they also bring in wider issues such as family problems, social care packages, equipment needed or lifestyle problems. Any problem set to impact on the health of the patient is then dealt with by the most appropriate member of the team, usually through a home visit. This alleviates pressure on GPs who do not need to spend time calling social care services or trying to organise other services in short appointments.

However, sometimes the existing legislation can make this type of working more difficult than it should be by creating barriers between different bits of the health and care system.

The proposed integration measures in the Health and Care Bill will make this type of joint working easier, both within the health service and between the health service, social care and local government. These measures include establishing Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs) (see factsheet on Integrated Care Boards and local health and care systems), removing barriers to joined-up working and promoting integration across healthcare, public health, and social care throughout England.

What the Bill will do

The Triple Aim

The ‘Triple Aim’ (referred to as the ‘duty to have regard to wider effect of decisions’ in the Bill) was one of the NHS’s legislative recommendations to government. It is a proposed common duty for NHS bodies that plan and commission services (NHS England and ICBs) and that provide services (Trusts and Foundation Trusts).

It will oblige these bodies to consider the effects of their decisions on:

• the health and wellbeing of the people of England (including inequalities in that health and wellbeing)
• the quality of services provided or arranged by both themselves and other relevant bodies (including inequalities in benefits from those services)
• the sustainable and efficient use of resources by both themselves and other relevant bodies

These Bill provisions aim to encourage these bodies to not only continue a culture of working in the best interest of their immediate service users and organisations, but also on public health, prevention and reducing health disparities for the wider population, and will include working together strategically with other relevant bodies and the public. We hope that the Triple Aim will help align NHS bodies around a common set of objectives, thus supporting the shift towards integrated local health and care systems which have strong engagement with their communities. At report stage in the House of Lords, the government tabled amendments to explicitly include consideration of inequalities in health and wellbeing and the benefits of services in the Triple Aim.

Duty to cooperate

We propose strengthening 2 existing duties to cooperate with the addition of guidance-making powers for the Secretary of State. These duties apply between NHS bodies and between NHS bodies and local authorities. The intention is to use the flexibility of this guidance to give organisations greater clarity about what these duties mean in practice for particular services or in particular situations. For example, we see opportunities to use this power to share best practice in using the Better Care Fund, or in designing collective approaches to patient pathways.

Repeal of duties to promote autonomy

We are proposing to repeal the duty on the Secretary of State and NHS England to promote autonomy. This change aligns both with encouraging joint and cooperative working and with the Secretary of State’s new power of direction over NHS England.

Collaborative commissioning

The collaborative commissioning proposals (referred to as ‘joint working and delegation arrangements’ in the Bill) will allow for more joined up working between 2 or more ICBs, between NHSE and ICBs, and between ICBs and other parts of the system. The proposed provisions will make it easier for ICBs to commission and arrange services collaboratively with other partners by creating a mechanism for ICBs and NHS providers to delegate or jointly exercise functions and pool funds. Where NHS England or an ICB delegates a function as part of a collaborative arrangements, it will be expected to take appropriate steps to ensure that this function is being effectively carried out on its behalf. This will include the power to set the terms of delegation agreements, which can impose terms as to how the delegation powers can be exercised, including terms as to payment.

In practice, this means, for example, that NHS England could delegate responsibility for arranging specialised services to one or more ICBs. Specialised services are treatments and services which are planned and commissioned nationally and regionally by NHS England. By enabling ICBs to commission these services, we can encourage a more collaborative and integrated model of commissioning alongside locally-commissioned services, to ensure services are designed (and investment is made) with the whole patient pathway in mind.

Joint committees

Legislation does not currently allow NHS providers (NHS trusts and foundation trusts) and CCGs (which will be replaced by ICBs) to take joint decisions. This creates an unhelpful barrier to joint working, and commissioners and providers currently have to use workarounds with complex governance arrangements in order to jointly discuss integrated care, incurring legal risk and administrative cost. These proposals will create a legal mechanism for ICBs and NHS providers to form joint committees, make binding decisions and pool funds. These joint committees could include representation from other bodies such as primary care networks, GP practices, community health providers, local authorities or the voluntary sector. This will make it easier for organisations to work closely together and deliver more integrated care.

In practice, this mechanism may be particularly useful where an NHS trust straddles 2 ICB footprints, meaning, for example, that 2 ICBs and an NHS trust would be able to jointly plan and make joint decisions about hospital services across both ICB geographies.

Joint appointments

Joint appointments are allowed between NHS organisations, and between NHS organisations and local authorities and combined authorities. Joint appointments of executive directors can help to foster joint decision making, enhance local leadership and improve the delivery of integrated care. They can also help to reduce management costs and engender a culture of collective responsibility across organisations. The Bill would provide NHS England (as the new merged entity with NHS Improvement) with the ability to issue guidance on joint appointments, including on conflicts of interest, to ensure that there is a clear set of criteria for organisations to consider when making joint appointments

Care Quality Commission (CQC) reviews of Integrated Care Systems

The CQC is the independent regulator of health and social care in England. The Bill, following a recommendation from the Health and Social Care Committee, proposes a new role for the CQC in reviewing each local Integrated Care System as a collective endeavour. These reviews will assess the provision of NHS, public health, and adult social care, the activities of the Integrated Care Board, local authorities, and providers in relation to that care and the function of the whole system including the Integrated Care Partnership.

We expect that these reviews will initially look at the themes of integration, leadership, and quality and safety as priorities. They will provide the public and the system with independent assurance of how their area is performing and, in particular, the effectiveness of joined up working and integration.

How these provisions will help to promote integration

These measures will enable the NHS, public health and social care system to connect, communicate and collaborate so that the health and care needs of people are met.

These measures, coupled with the establishment of ICBs and ICPs, are designed to enable and promote this integrated patient-centred approach across all of England.

Further information

The NHS Long Term Plan, January 2019

The NHS’s recommendations to government and parliament for an NHS Bill, September 2019

NHS England and NHS Improvement, Implementing the Long Term Plan: proposals for possible changes to legislation, February 2019

Department of Health and Social Care, Integration and innovation: working together to improve health and social care for all, February 2021

NHS England and NHS Improvement, Integrated Care Systems: design framework, June 2021

Health and Social Care Committee, the Government’s White Paper proposals for the reform of Health and Social Care’ first report of session 2021-22, May 2021.