Another White Paper aims to join up care – some reflections

The first point of interest is that this is not a traditional white paper, setting out detailed proposals for legislation. Rather, it is guidance about how the central government departments DHSC and DLUHC would like Places to operate, taking into account the changes expected under the Health & Care Bill. Many of the things it talks about can be done now – before the Bill becomes law. And while it includes questions for consultation, it is not a formal consultation document that readers are invited to respond to and give feedback on.

In practice, the document covers much the same topics as the Thriving Places guidance issued by NHS England, NHS Improvement and the Local Government Association in September 2021. For example, the White Paper builds on the discussion of Place governance in Thriving Places by setting some criteria for Place governance.

Central government’s role in issuing the white paper could be an indication that DHSC will be taking a more active role in issuing operational guidance to the sector. This mirrors one of the themes of the Bill – increased powers for the Secretary of State for Health & Social Care.

While the white paper does talk about formal joint decision-making under section 75 of the NHS Act 2006, equal weight is given to aligned decision-making. This is perhaps recognition of the difficulty of getting genuine joint decision-making and pooling of funds going on the ground. Use of pooled funds means that organisations lose some control over their spend. Use of joint decision-making means that an organisation is no longer in sole charge of its destiny. These risk-based approaches therefore require the presence of both a high degree of trust between partners and a level of financial security for each partner.

Aligned decision-making is a much easier sell, as individual organisations retain control over their budgets and there is no risk that an organisation can be “overruled” by its Place Partners. In our experience, it is much more common for Place Partnerships to look to better alignment as the next stage in collaboration.

The fact that alignment is given equal billing to formal joint working feels like a subtle shift in emphasis, and recognition that true joint decision-making on the ground is difficult to achieve.

The White Paper refers to each Place having “a single person, accountable for the delivery of the shared plan and outcomes for the place, working with local partners”. The person should be appointed to this role by the relevant local authority/ authorities and the Integrated Care Board (ICB).  

US Secretary of State, Henry Kissinger is said to have demanded “Who do I call for Europe?” when faced with a plethora of national politicians vying for position. It appears that the white paper is answering a similar question of “Who do I call for Place?” – ensuring there is a single point of contact for local leaders, the public and national regulators.  

The white paper clarifies that the appointment of the single accountable person will not affect the responsibilities of the local authority or the ICB Chief Executive. As such, the term “accountable” is being used in a looser sense of someone who reports to, is appointed and removed by, the ICB and partner local authorities. It does not mean someone who has a statutory responsibility to e.g. report to Parliament on finances.

Many places already have “Place Leads” in position, whose appointment has been agreed by local health and care partners. We would expect that in many areas, the ICB and partner local authorities will make clear that this is the person they have appointed as their single accountable person.
 

This white paper is the third white paper in recent years to discuss the amendment of the regulations governing joint decision making and the pooling of funds between local authorities and the NHS. These regulations are known as the section 75 regulations and set the rules about how joint committees and pooled funds set up under section 75 operate.

There are some points where it would be helpful to update the regulations. The main one is to reduce the list of services that cannot be subject of joint decision-making and pooling of funds. Services that cannot be part of such arrangements include surgery and radiotherapy. Reading the list of exclusions today it is difficult to see why such services should be excluded.

However, it is not clear what other changes could be made to help drive greater use of section 75 arrangements. In our experience it is not the regulations that get in the way but the will of the organisations involved to pool resources and share risk. This is particularly the case when budgets are stretched.

The white paper focuses on changes that could be made to the rules about pooled funds, rather than joint decision-making generally. It is not clear what aspects of those rules the DHSC and the DLUHC consider need to change, and there are some questions that will, in time, go out to consultation. But those questions are very high level and don’t appear likely to prompt feedback about the legal drafting of the rules themselves – more the practicalities of risk sharing on the ground.

We have been expecting a general overhaul of the section 75 regulations for some time. But now the timing and policy intent behind such changes is less clear. And it appears that any changes will be focussed on the mechanics of pooled funds rather than the services that can be the subject of section 75 arrangements.

There are a couple of strong themes in the introduction to the white paper that don’t quite feed through into the sections that talk about the practicalities of delivering at Place. The first of these is the importance of housing as a wider determinant of health. And second, the importance of levelling up (expressed that way, rather than in the more traditional language of tackling health inequalities).

This is not surprising given the white paper is co-authored by the Secretary of State for Health & Social Care and the Secretary of State for Levelling Up, Housing and Communities.

It is not clear if/how the levelling up agenda differs from the long-standing efforts around health inequalities. The recent Levelling Up the United Kingdom white paper identified a “mission” of reducing local variation in healthy life expectancy (HLE) by 2030 and the goal of increasing HLE by five years by 2035. The levelling up policy programme led by the DLUHC is focussed on improving public health, supporting people to change their food and diet and tackling diagnostic backlogs. We are expecting a further white paper on health disparities later this year.  The Levelling Up white paper also commits to setting up at least 100 Community Diagnostic Centres in England by 2023 to boost diagnostic capacity.

Although these themes don’t flow through into particular requirements, for example around Place governance, ICBs and Places would do well to make sure they have a strong story to tell both on tackling housing issues as a wider determinant of health and on levelling up. It is likely that these will be the focus of future guidance from the DHSC and DLUHC. This is especially the case for levelling up, given the received wisdom that it is a central plank of the government’s re-election strategy.

Eleanor Tunnicliffe, Esther Venning, Emma Stockwell, Rob McGough