The House of Lords Committee on Integration of Primary and Community Care

The House of Lords Committee on Integration of Primary and Community Care has published its report.

Conclusions:

• ICSs need stability and continuity to develop more fully. Structures should be given time to mature and evolve; and for constraints on their performance to be well understood. The 2022 Act’s underlying principles of subsidiarity and collaboration should continue to inform any future reform to the structure of services. These principles commanded wide support from witnesses, irrespective of the diversity of opinion on the overall merits of the 2022 Act and wider health policy.  
• Health, social care, and voluntary sector leaders should work together closely as equal partners, as they are likely to possess a deep understanding of their respective communities. This will encourage integrated policy making and service provision, as well as a more preventative approach to public health. There should be a single accountable officer at place level, specifically charged with working with local leaders of providers, the voluntary sector, and local elected officials. There is a need for local champions, keen to drive integrated working, to explore local barriers and find local solutions. Their job appraisal should be focused on their effect on reported outcomes from those delivering and those receiving front-line care.  
• ICSs were created to ensure that services are well co-ordinated and that decisions are taken at the lowest appropriate level. In addition to assessing safety and leadership, the CQC needs to develop a more granular measure of the level of integration. This would enable long-term tracking of ICS Patients at the centre: integrating primary and community care 7 maturation, which will help measure the success of the reforms put in place under the 2022 Act.  
• Primary and community clinicians should work more collaboratively at place and the individual patient levels. Their work should put a greater emphasis on public health and preventative health care.   
• GP practices should be housed in buildings that facilitate integration by acting as a physical hub where primary and community clinicians, together with other services, are co-located, sharing space for multi-disciplinary practice, planning, and training.  
• Patients in the community should be treated by a multi-disciplinary team of social care workers, community nurses, their GP and other specialist community clinicians like podiatrists.  
• Devolved, place-based commissioning and funding should be the default option. Local stakeholders have a close knowledge of local needs and understand how services can work together.   

Recommendations:

1. ICSs should be given time to mature and further wholescale reorganisation to the health service should be avoided. The DHSC should ensure that ICS structures are subject to a thorough and ongoing long-term evaluation before any further major reforms to the health service are implemented. This evaluation should consider the extent to which ICS structures and processes have successfully facilitated improved integration within the different sectors of the NHS, and between the NHS and other stakeholders; and whether any further guidance or change in primary or secondary legislation might secure better outcomes from integration. It could be similar in scope to the recent Hewitt Review, but with the benefit of three years-worth of data and experience, rather than just one.   
2. Elected local government officials should be granted the right to chair Integrated Care Boards (ICBs). Representatives of VCSE organisations should be allowed to be members of Integrated Care Boards. This would encourage integration by allowing elected officials responsible for social care, as well as voluntary sector service providers to direct the work of ICSs, as well as health service leaders. Directors of Public Health should be statutory members of ICPs. These three targeted changes can be enabled by amending the Health and Care Act 2022.   
3. The Government should provide an update on its plans for a single accountable officer at place level. The Government should also give more detail on how this role would be equipped to deliver on local health needs and how their work would be scrutinised.   
4. Coterminosity of ICS and local authority boundaries should be a long-term aim for the Government and a consideration when implementing future local government or health service reform. Greater coterminosity would make any future integration of local health and social care budgets more straightforward.  
5. In addition to authorising the new CQC ratings for ICSs, the Secretary of State should instruct the CQC to develop a specific “integration index”. This would evaluate and compare how well ICSs co-ordinate different services in their area. This should be in addition to the overall qualitative ratings and would give greater granularity than the planned 1–4 scale.  
6. The Government should ensure that the CQC pilot studies are widely disseminated and reviewed. Maximum engagement in the CQC studies will lead to a better inspection regime for ICSs.   
7. The DHSC and NHSE should comprehensively reform and align primary and community care contracts to incentivise integrated working. Any new national contract should permit a high level of flexibility for the ICBs carrying out primary care commissioning.   
8. To facilitate co-located, multi-disciplinary working for primary and community care, the DHSC should investigate different ownership models for GP practices, their co-location with other community services and how it can support ICSs and local authorities in exploring these models.  
9. The Better Care Fund should be enhanced to cover a larger proportion of relevant NHS and local authority expenditures.
10. The Government should bring forward changes to the Health and Care Act 2022 to require, rather than permit ICBs, to establish place-level committees. These will be responsible for commissioning relevant health and local authority services and committing resources in line with local Integrated Care Strategies.