Our beloved NHS will mark its 75th anniversary on 5th July 2023. Rightly, this will be cause for celebration. The fundamental principle that the NHS remains free at the point of use has been maintained since 1948 and, whilst the NHS has been challenged over the last few years like never before, the 1.4 million people who work in the service remain as committed to its mission and values today as any day since it was formed. We know that current public satisfaction with the NHS is not where we would like it to be and, across the NHS, colleagues are working hard to improve the speed, quality and safety of the services it offers.
For the NHS to survive for another 75 years, it must change to reflect the world as it is today and will be, rather than the world as it was when Aneurin Bevan led its establishment. The country that the NHS is here to serve is changing, people’s expectations are changing and the NHS must meet these.
A changing landscape
Whilst life expectancy has stalled since 2011, and for certain groups it has gone into reverse, research by The Centre for Ageing Better shows there are now 11 million people aged over 65; a 52% increase since 1981 and that number will increase to 13 million by 2033, which will be 22% of the population. Whilst this should be a cause for celebration, our changing demography will put more strain on the NHS and, of course, social care. The same research also reports that 2.1 million men and 2.2 million women aged between 45 and 74 live alone and there has been a 68% increase in the figure for men since the year 2000. Currently, 22% of men and 33% of women provide unpaid care to a loved one. All of this data suggests that we will need more social care than we have now.
It’s not just our ageing population that is putting the NHS under pressure. More and more of us are living with long-term, life-limiting conditions that are putting even more strain on the NHS. For example, obesity and the health conditions that arise from it cost the NHS around £6bn annually – this is forecast to increase to £9.7bn a year by 2050. The Building Research Establishment (BRE) Group’s 2021 report The Cost of Poor Housing found that poor-quality housing costs the NHS over £1.4bn a year. Unless we do things differently in the future, the 11.9% of the UK’s GDP that we currently spend on healthcare will grow to levels that the country will be unable to afford.
It is against this backdrop that the 2022 Health and Care Act was introduced, resulting in the establishment of 42 ICSs across England, covering populations of between 500,000 and three million people. The King’s Fund has provided a simple description of an ICS as ‘…partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas’ – but that I’m afraid is where simplicity ends. It has been said (more than once) that when you’ve seen one ICS, you’ve seen all ICSs. However, ICSs are complex ‘ecosystems’ made up of Integrated Care Boards (ICBs), which have taken on the old Clinical Commissioning Group’s responsibilities to plan, commission and fund NHS services, as well as being a catalyst for change across NHS services, along with Integrated Care Partnerships (ICPs), which bring the NHS, local authorities together with system partners, including the voluntary, community and social enterprise sector, and others together to develop a health and care strategy for the area.
Joined-up approach
Integrated care systems have four key aims. To:
- Improve outcomes in population health and health care.
- Tackle inequalities in outcomes, experience and access.
- Enhance productivity and value for money.
- Help the NHS to support broader social and economic development.
Whilst these aims are universal across all 42 ICSs, how each one delivers them will be different based on their local circumstances, but what is clear, enshrined in the 2022 Act and is non-negotiable is that collaboration will be the foundation on which ICSs will be built, with a focus on place and local populations rather than the previous world of competition and organisational autonomy. There is clear evidence (see infographic below) that the clinical work of the NHS only accounts for around c20% of a person’s health and wellbeing, with the remaining 80% depending on other factors such as the quality of housing you live in, how much you earn, how much exercise you take, how much you smoke, etc. All are factors outside of the NHS’s control.
For the Star Trek fans reading this article, when I first became Chair of NHS Kent and Medway, I used to describe ICSs as being similar to the three-dimensional chess games played by Mr Spock and Captain Kirk on the bridge of the Starship Enterprise. Now, after being officially in existence for nine months, I think ICSs are more like trying to complete a Rubik’s Cube!
For obvious financial, organisational and political reasons we cannot establish truly ‘integrated’ care systems, because what we know is that we have an ‘interdepedent’ care system whereby the principle of mutuality is at its core. But this brave new world of collaboration will not happen overnight. It will not happen because any one and/or group of people say it must be so. It will take time. Every organisation within an ICS will need to change. It will take leaders from all sectors to listen with authenticity and act with humility to work very differently in the future.
As a former social provider chief executive, I became more and more frustrated that the NHS felt impenetrable and impossible to deal with on any level and the NHS was disconnected from local authorities, leaving many service users and residents whose care and support my organisation was responsible for in difficult and sometimes distressing situations. Our collective challenge as ICSs develop and mature is to work together very differently. Our local communities deserve no less.
Better together
With social care funding continuing to be challenging, with around 160,000 social care staff vacancies, a 29% annual staff turnover rate, 500,000 mainly older people waiting for an assessment, review, care package or direct payment, combined with the average of 13,400 people a day being in hospital, despite no longer meeting the criteria to stay (as of December 2022), which is a 30% increase since December 2021, the picture does indeed look bleak. However, I believe that together, whilst we may not be able to replace the reduction in the People at the Heart of Care funding announced recently, it remains in ICBs’ interests and that of the wider ICS for the NHS to work with social care providers on the workforce development agenda and on local recruitment and retention initiatives. Despite also being under huge financial pressure in 2023/24, ICBs have the financial flexibility to work with social care providers on ‘Invest to Save’ initiatives, projects and programmes, but social care providers – be they in the residential care homes or domiciliary care sector – need to be engaged with ICBs either directly or through their local care associations. If investing £5 directly in social care, for example, training social care staff in new and different areas of work, and potentially reducing social care staff turnover saves an ICB £6, then that’s £5 of ICB money well spent.
The recently published Hewitt Review highlights the real and significant opportunities for ICS partners to work together to ‘reimagine’ social care and create a sector that is secure over the long term. The NHS needs to work with social care to provide more rehab beds, more stepdown and intermediate care beds and more reablement support for people who need to be discharged back into their own homes. ICBs cannot afford to allow their local social care sector to wither on the vine with providers handing back contracts, closing care homes and exiting the market.
One of the biggest challenges facing ICBs is how do we move the money around? How do we review and reconfigure our investment profile to give us more available money to spend in new and different ways in primary and community healthcare, as well as in social care?
We are all standing on a burning social care platform. If we can’t see the flames, then surely we can smell the smoke and feel it getting warm under our feet.
I’m becoming well known for repeating the mantras, ‘We can’t fix the NHS until we fix social care’ and ‘The answer’s leadership. Now, what’s the question?’
This graphic shows the wider determinants of health and wellbeing, with only 20% being directly related to the NHS.