Integrated care systems: accountability for place based health and care

The Government’s White Paper Joining up care for people, places and population (9 February 2022) is its second within (just) under a year about health and care integration following its first one Integration and Innovation: working together to improve health and social care for all (11 February 2021).

The NHS has been crying out for integration since its inception. The two White Papers are the latest iteration in a long history of policy that has repeatedly found integration as elusive as the legendary El Dorado. Continuing only to do what has already be done risks the retort, ‘I have seen the future and it hasn’t worked.’ So where do the White Papers take health and care bodies on the search for integration?

The first White Paper targeted complex and/or bureaucratic ‘workarounds’ including six such mentions of current governance arrangements for integrating health and care at place level. It proposed that two forms of integration (intra-NHS and NHS-other) should be underpinned by legislative changes to be made by the Health and Care Bill, but left place level governance to local organisations to arrange, including the critical issue of accountability.

So whereas the first White Paper word cloud was heavy on both accountability (54 mentions) and legislation (97) the second continues to be heavy on accountability (36) but light on legislation (3). It does not propose any new draft legislation on top of the Health and Care Bill beyond the relatively small detail of a review of section 75 of the NHS Act 2006 (which allows partners such as NHS bodies and councils to pool and align budgets) to simplify and update the underlying regulations.

Not for nothing did the first White Paper warn that integration may add complexity and requires thoughtful handling within systems with respect to governance and accountability. Both White Papers suggest that (as always with integration) the devil will be in the detail of place based arrangements.

It is therefore no surprise that the second White Paper emphasises that effective integration and local prioritisation require both a strong, shared sense of purpose and clarity of accountability at place level. It outlines key features of a governance model that it suggests will be:

• A single person, accountable for the delivery of the shared plan and outcomes for the place, working with local partners
• A 'place board' that brings together partner organisations to pool resources, make decisions and plan jointly
• Integration of decision-making through formal governance arrangements (likely to include definition of membership; responsibility for outcome-setting; responsibility for delivery of functions or programmes delegated; financial arrangements including pooling; and dispute resolution and decision-making).

It goes on to say that a council and ICB may delegate their functions and budgets to the place board but purposely avoids prescribing accountability arrangements. And while there is flexibility in what governance arrangements might be, there is a fixed deadline of 1 April 2023 by when they must be in place, so the next year 2022-23 may be an opportunity to be grabbed with both hands not only to develop such arrangements but also to run them in trial mode before they are load bearing.

Here at Browne Jacobson we are advising clients including nascent ICSs about place-based arrangements. Going forward such arrangements will need to be more formalised (if not already so) to ensure clarity and transparency of accountability which critically would include formal delegation. 

So whilst the latest White Paper does not propose substantive new legislation on top of the Health and Care Bill, we think there is already more than enough in the Bill for health and care statutory bodies to overcome historic barriers to integration and set up new place level arrangements with clear accountability for joint working and delegation without the bugbears of complexity and bureaucracy. If you ask us how, we will be happy to help.