A Business Perspective
On this page, we share our thoughts and comments on current issues in the health, care and social business market place, including any general learning from our work, when we think that might be useful. We also include links to any articles or blogs we have been involved with.
White Paper on “Integration and Innovation: working together to improve
health and social care for all"
Significant NHS reform is on the way as set out in the Department of Health and Social Care’s White Paper on “Integration and Innovation: working together to improve health and social care for all” and which was published on the 11th February 2021. The intention is to bring in the new proposals through a new Health and Care Bill to become effective in 2022. The White Paper is the result of a number of factors, including the need to bring the Law up to date to capture developments that have taken place operationally as the NHS has got to grips with providing a more integrated service for patients, and to start implementing some of the lessons of Covid-19.
A key proposal is to create new statutory “Integrated Care Systems” or ICSs. These will be new legal bodies which will contain commissioning skills as well as provider experience with, for example, NHS Foundation Trust and NHS Trust representatives on the board of the ICS. These new bodies, whilst having a commissioning function, actually start to rub away the very sharp “commissioner/provider” split that currently exists because provider bodies which will receive funding from the ICS will also have representation on the board of the ICS.
As well as having a core “ICS NHS Body” role, each ICS will also be required to establish as part of their structure an “ICS Health and Care Partnership”. This partnership body will be responsible for developing a plan that addresses the wider health, public health and social care needs of the system and the ICS NHS Body and Local Authorities will have to have regard to that plan in decision-making.
The ICS NHS Bodies will have a Board with a Chair and a CEO and representatives from NHS Trusts, General Practices, local authorities, and others determined locally, such as from community and mental health services, and they will also have Non-Executive directors. Members of the ICS Health and Care Partnership could be drawn from a number of sources such as Health & Wellbeing Boards, Healthwatch, voluntary and independent sector providers and social care and housing providers. The ICS NHS Body will be responsible for the day to day running of the ICS, NHS planning and allocation decisions, including a plan to address the health needs and strategic direction of the system and explaining the capital and revenue spending of NHS bodies.
Other key aspects of the White Paper include the right of Government to set Capital Departmental Expenditure Limits for named Foundation Trusts (to ensure sustainable use of NHS resources), new powers to create joint committees between organisations, increased powers of collaborative commissioning across ICS areas and the ability to make joint appointments across NHS bodies. There will also be increased data sharing to aid health and wellbeing, enhanced patient choice measures and removing the application of some of the competition and procurement laws on the health service. In relation to the latter for example, the Competition and Markets Authority will not have its current remit to review hospital mergers and the current tendering rules will not apply to healthcare services.
As the White Paper states, it is not just new legislation that is important, but “having the right workplace in force; good leadership at all levels” is also needed. This is an issue which is perceptively highlighted in a book called “The Story of Your Healthcare” by Bob Phillips published by Bloomfield Press, a book which describes and explains the journey of Your Healthcare Community Interest Company, a social business provider of NHS community services, to commemorate Your Healthcare’s first ten years in business. Bob Phillips refers to the fact that sometimes the concept of “fully integrated” is seen by the top of the NHS as something integrated across the whole of the landscape, but Your Healthcare CIC’s concept of “fully integrated” is something experienced on the ground in the community. Patient orientated integrated care is really a function of how the front-line staff think about and practise their work. As one of the patient’s said “…But I didn’t mind asking the YH District nurses because I know them and they know me. I knew also that it would take them only a couple of minutes to look. I know they wouldn’t mind advising me whether I needed to go to the GP or what I needed to do. One thing I know about YH staff, they wouldn’t say: “feet isn’t my thing”- they wouldn’t just say that and leave you to wonder “What do I do now ?” they’d say : look, this is what I suggest you do.” …..
Personal Health Budgets
These are all fine words but a key question for patients and carers is how quickly can some of the professionals really change the way they have been working to date? How quickly, for example, can they find new ways of co-operating with patients and carers through personal health budgets (PHBs)? It is perhaps worth acknowledging, however, that not everybody seems to believe that patient views really matter when care decisions are being taken. Many people have considered this issue formally, trying to show practically and scientifically that listening to patients makes good sense. The very debate indicates that listening to patients and trusting them to be their own commissioners is not an automatic step for everybody and some hearts and minds are still to be won. This is so despite DHSC and NHS England consultations revealing strong support for PHBs and Matt Hancock’s words that “Everyone deserves the right to make decisions about their care, and health and care should be centred around each and every one of us, not a one-size-fits-all approach”.
The NHS Long Term Plan noted that the Comprehensive Model of Personalised Care is already being implemented. By September 2018 over 200,000 people had already joined the personalised care programme and over 32,000 people had received PHBs, nearly a quarter of which were jointly funded with social care. In fact, figures released from October 2019 show that the 32,000 PHBs figure had moved up to 70,000.
The Long Term Plan states that the NHS will accelerate the roll out of PHBs to give people greater choice and control over how care is planned and delivered and up to 200,000 people will benefit from a PHB by 2023/24. This will include provision of bespoke wheelchairs and community-based packages of personal and domestic support and there will be an expanded offer in mental health services, for people with a learning disability, people receiving social care support and those receiving specialist end of life care. Indeed from the 2nd December 2019, everyone eligible for an NHS wheelchair and people who require aftercare services under section 117 of the Mental Health Act have had access to a PHB. Of course adults who are eligible for NHS Continuing Healthcare funding have had a legal right to have a PHB since October 2014. For the latest NHS England and NHS Improvement guidance on PHBs please see their document “Guidance on the legal rights to have personal health budgets and personal wheelchair budgets” dated December 2019. (https://www.england.nhs.uk/wp-content/uploads/2014/09/guidance-on-the-legal-rights-to-personal-health-budgets.pdf)
Again fine words in relation to target numbers in the NHS Plan for PHBs, 200,000, but if they are to be achieved then NHS England, CCGs and councils really need to focus even more seriously and more quickly on this whole area including how they all cooperate and coordinate their actions and decisions. The legal and regulatory mechanisms are substantially in place to effect and enable the required change in pace and scale for PHB uptake. But more debate about what the most difficult barriers to the pace of change in PHBs is needed, and how those might be countered and overcome and also what we all need to do to give PHBs the best possible chance of actually improving care, including the patient experience of living and dying.
Please note that the Government has acknowledged the importance of everybody receiving the care and support they need throughout the Covid-19 pandemic and further guidance has been issued and updated on the 11th September 2020 and is called “Using Direct Payments during the coronavirus outbreak: Full Guidance for People Receiving Direct Payments and Personal Assistants.” (https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-for-people-receiving-direct-payments/people-receiving-direct-payments-and-those-they-employ-quick-read)
Metamorphosis has been said to be a dynamic principle of creation, vital to the natural process of generation and evolution, growth and decay! We often think structures that we put up will last for ever but quite often this is not correct. We see buildings change and adapt before becoming obsolete, demolished and a new building going back up when needs change. The same is true of companies or other corporate structures that organisations use to deliver their services. These business structures can change, they can adapt, they can be dissolved and new organisations created. These metamorphoses are going on all the time in the community as organisations adapt to changing finances or to community needs, or the desire amongst organisations to work more closely together or dealing with the consequences of winning or losing contracts.
Over the last few months, we have supported a client begin the process of dissolving a charitable company that was no longer able to access the necessary funding to continue its good works. But, in another case, we have supported and drafted the application to the Charity Commission for a new Charitable Incorporated Organisation as a client looks to support capacity building for its local community to improve health in its area. We have helped redraft a Community Interest Company's Articles of Association to enable it to be owned and managed in a different way, to support better voluntary organisations in its locality to improve the local care and health agenda. Finally, we have been supporting a Community Interest Company that has won a new contract to provide community health care and needed to enter into business transfer agreements with those companies whose staff and assets were transferring to it to start performing the services from April 1st, 2020.
Despite the impact of the Corona virus and the difficult financial pressures, healthcare organisations, social businesses and charities are continuing to adapt and flex and re-engineer themselves so that they are in best position to support their clients, residents and patients over the coming year.
Please see a recent blog by Chris on the role of Community Interest Companies under the NHS Long Term Plan by clicking on the link below: