The new White Paper on integration of health and social care Joining up care for people, places and populations has an early warning of how vacuous much of its content will be: pictures of smugly grinning Sajid Javid and Michael Gove.

The document instantly fails the Lowdown’s quick test of seriousness: it has just four instances of the ‘£’ sign in 70 pages, confirming that it does not discuss finances – and of course without financial resources its various vague ideas and promises are simply empty words.

The Foreword gives more grounds for concern, in fostering the illusion that – even if they were available – “universal access to high-quality treatment and support in all parts of the country” would be sufficient to bridge the growing gap in healthy life expectancy between rich and poor areas.

The social and economic inequalities, which have been systematically widened since 2010, and more rapidly widened since 2019 despite the rhetorical commitment to “levelling up,” are such a fundamental social determinant of health that even the most lavishly funded NHS and social care would not compensate for them, let alone the brutally under-funded services that struggle through after a decade and more of real-terms cuts.

The Foreword also highlights proposals that are potentially controversial with NHS and local government, and with health and social care staff.

NHS Providers’ response highlights the lack of either a workforce plan, or adequate funding in health and social care:

“While the aspirations for a more integrated health and care workforce is welcome, the paper fails to acknowledge the scale of staff shortages in the NHS and social care sector and the national action required to tackle them. …

“… Pooling NHS and social care budgets is no substitute for funding both systems appropriately and placing social care services on a sustainable footing.”

It is equally unlikely that seeking effectively to pool staff between the very different, under-staffed  health and social care systems can work, despite the White Paper seeking to “create a more agile workforce with care workers and nurses easily moving between roles in the NHS and the care sector.”

While many staff working for low-wage, exploitative private companies delivering social care may well aspire to the superior pay, terms and conditions of their equivalents in the NHS, there are few, if any, grounds to believe NHS staff might happily swap places in the other direction.

NHS Providers notes the disparity in funding of the two systems, stating:

“We remain concerned that this approach [pooling budgets] would risk the NHS budget becoming exposed to severe and well-established funding pressures in social care.”

With no significant increased revenue funding or investment on offer to either health or social care, the fantasy world of Tory ministers seems even more ridiculous as they aspire to a completely unattainable notion of “integration”:

“Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole.”

A starker contrast with the actual dysfunctional, fragmented, privatised and cash-starved services is difficult to imagine. And, when it’s not so much lack of information as lack of hard cash that is blocking progress, the White Paper’s misplaced belief in the magical powers of data is also incongruous:

“Unlocking the power of data across local authorities and the NHS will provide place-based leaders with the information to put in place new and innovative services to tackle the problems facing their communities.”

Once more this is at complete variance from the likely outcome of half-hearted investment in unproven and disconnected whiz-kiddery while core services lack staff and resources. The White Paper is a wish list rather than a vision – while staff and service users on the ground face the harsh reality.

Putting the daft into draft proposals

NHS Providers has warned of the additional complications of requiring a single person to be “accountable for delivery of a shared plan at local [‘place’] level,” warning:

“Introducing a single person accountable for health and care at place, and expecting greater pooling of NHS and social care funding – without altering the underlying financial flows, infrastructure and accountabilities – will introduce further risk into an already fragile, and under-funded, system.”

NHS Providers also warns of the growing complexity of the system proposed by the Health and Care Bill, which would establish 42 Integrated Care Boards (ICBs), and larger numbers of Integrated care Partnerships (ICPs), answerable to NHS England/Improvement (NHSE/I):

“It is very striking how many trust leaders are currently saying that accountability between trust boards, ICBs, ICPs and NHSE/I regions feels very opaque and potentially confused. …

“… In particular, it is hard to see how a single leader can be accountable for the delivery of shared outcomes across the NHS and local authorities given existing statutory accountabilities for both systems will remain in place. This will lead to much greater complexity and high levels of risk being carried across all the different players in a system.”

One example of this is in Norfolk and Waveney ICS, wher the chair of one of the acute trusts has broken the usual polite silence by declaring that the proposed structure of the ICS, involving no less than twelve separate bodies, is “absolutely daft,” and she was “struggling to navigate what each group does”. A look at the document from the “interim partnership board” confirms her view, explaining the complex network of bodies beneath the ICB:

“We are creating five local health and care alliances (‘Alliances’) based on our current health localities. … They will be accountable to our Integrated Care Board (‘ICB’).

“We are also creating 7 local health and wellbeing partnerships (‘Partnerships’) alongside our Integrated Care Partnership (‘ICP’) to progress our work on addressing the wider determinants of health, improving upstream prevention of avoidable crises, reducing health inequalities, and aligning NHS and local government services and commissioning. These partnerships will be based on district footprints.”

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