On 19th April 2018, I attended the Westminster Health Forum Keynote Seminar on Next steps for place-based care, integrated care systems and health and social care devolution in England. The Health and Care Devolution MoU (memorandum of understanding) came into effect in November 2017, the full text is available here: bit.ly/2F72Trt.  

The primary objective of the MoU is to implement an advanced form of decentralisation, passing decision-making powers down to a local level where the Health Care Authority and Local Government work together to determine the health and care needs for their local population.

“Devolution is not simply about transfer of powers or functions but presents an opportunity to work in different, more integrated ways.”

Will Tuckley, Chair, London Health and Care Devolution Programme Board and Chief Executive, London

This would be achieved by the introduction of Integrated Care Systems (ICSs), which would be built up stage by stage using pilots, working within the devolution framework to overcome barriers.

Will Tuckley highlighted an unanticipated issue at the beginning of the process, namely prevention, as the sticking point between local and national institutions. It is now accepted that the current centralised system is no longer fit for purpose. But there are serious institutional, legal and historical obstacles facing the implementation process. 

Dr Eric Kelly, Chair of Bassetlaw CCG, in his presentation 'The potential for integrated care systems in joining up services', described how the current centralised system is too fragmented to be effective in supporting patients, with patients not knowing where and how to access the system and services not communicating effectively with one another. In Bassetlaw, they are working to encourage representation from Education and are currently in discussion with a view to include health education in the school teaching.  

Charlton Manor Primary in Greenwich, South London is a success story in health education. Delivering the National Curriculum through Food www.charltonmanorprimary.co.uk was developed for the prevention of childhood obesity, dental decay and other preventable conditions. 

In the two years since the Devolution MoU has come into effect, Wave One Devolution Agreements have been rolled out to a number of areas in the form of pilot Integrated Care Systems (ICSs), which currently support 11.8 million of the population.

By this time next year, it is envisaged that more than half of England will be covered by ICSs.  A second wave of ICSs is expected, with the potential for 25 million people being covered by this time next year (a rise of 6.8 million in Wave Two).

Wave One Devolution has facilitated the emergence of hotbeds of experimentation, with promising results.  The Lightbulb project from Leicester, Leicestershire and Rutland recently won an LCG award. The project aims, "To help people stay safe and keep well in their homes for as long as possible," using an integrated approach.

The Better Care Fund (BCF), announced by the Government in June 2013, is an ambitious project spanning both the NHS and local government with a view to joining up health and care services.  Rosie Seymour, Deputy Director of the Better Care Support Team, outlined that their aim as, “To breakdown organisational barriers so that health and social care can deliver the right care, in the right place, at the right time, and join-up services so people can manage their own health and wellbeing.”

Currently, the Better Care Fund is working to a two-year planning process.  Their policy framework 2017-19 must meet specific National Government conditions, such as that it should be a jointly agreed plan.  The total size of the fund stands at approximately £8bn for this financial year, with £1bn ringfenced for out of hospital commissioned services.  The impact of the BCF relies on collaboration, innovation, and system redesign.  Rosie Seymour reports that there is strong feedback nationally that reforms are working and that things are coming together.

As of April 2018, the Social Care Institute for Excellence (SCIE) have made a digital tool available to support local planning and inform ongoing developments across government. 

The Future of Devolution

Will Tuckley highlighted that the key commitments of integration have been identified as building partnerships and models of care from the bottom up, delivering community-based care and keeping people out of hospital.

Organisations will be brought together around the population they serve, with a "learn as we go" approach to enable the benefits of shared learning from those who have paved the way. Strong evaluation programmes will be needed, and, crucially, a model from the centre should not be sought or imposed. The pilot in Greater Manchester has demonstrated the possibility of freeing up the local area to some degree, whilst still being connected to a National system.

Another key factor to the success of the scheme will be for collaborators - the NHS, Local Government, and Social Care leaders, will commit to shared learning and collaboration to conclude an agreement on what they want to achieve.

Overcoming the Challenges

In 2018 the key players from the original Devolution deal have since moved on; a consequence of government reform that Devolution hopes to safeguard against.

Those involved with implementing the reforms are finding it to be a slow process, with a constant pressure for standardisation.  As Dave West, Senior Bureau Chief of the Health Service Journal, pointed out, there will still be no ACOs (Accountable Care Organisations) in England by this time next year.

Surrey, another Wave One pilot, expressed a lack of clarity about who is in control of the process.  Surrey County Council went so far as to set up a parallel body to manage their response to the STPs. With phased Devolution, there is concern that this will negatively impact the bidding process for funding, creating a gap between STPs that are more advanced. There is also concern about how to manage expectation, once the scaling up process begins, against the general expectation of the public from the NHS. 

Clinicians, who are not against integration and as frontline practitioners have a valuable contribution to make, feel largely left out of the discussion at present.  Lord Mawson, Executive Chairman of Well North, emphasised the fact that good people are retiring early because of the existing system.  These older people have wealth of knowledge that could contribute to the devolution debate/reform.

The reluctance of organisations to share the findings of case studies is proving challenging.  Organisations have been reluctant to engage in data sharing, which prohibits a shared-learning approach.  Rosie Seymour suggested the possibility of introducing a trouble-shooting wheel to prevent organisations from falling into the same pitfalls.

Devolution can't be driven by the centre, it must come from local areas.  There is a strong feeling that experience and learning should inform the evolution of the system.  Local areas know better than anyone how to deliver real change in their area.

However, it is apparent that clarity of terms is needed. Going forward, the control of the decision-making process will need to be devolved to local areas in a much stronger way.  A more fruitful argument is required than who is legally accountable.

Jonathan Walden, Commissioning Policy Lead of the Department of Health and Social Care reassured that the Government remains committed to Devolution.  They are eager to see progress and learning, as this will shape the future of further Devolution deals.

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Caitriona Fitzsimons Digital Reporter