- The commitment to introduce a Bill to promote integrated care is very welcome. It is vital that ministers and NHS leaders set out a compelling narrative for how these changes will improve patient care.
- Proposals in the health and social care White Paper to improve workforce planning are inadequate. A fully funded workforce strategy is needed to address staff shortages, boost retention and promote compassionate and inclusive leadership.
- The Queen’s Speech once again falls short of a meaningful commitment to reform social care. To honour his promise to fix the social care system, the Prime Minister should set out proposals for reform and new investment without further delay.
- If the government is serious about its commitment to levelling up, it must address the deep and widening health inequalities between our richest and poorest communities.
The Covid-19 pandemic has shown the health and care system at its best. Health and care workers have responded with outstanding dedication and skill (Oliver 2020), clinicians and managers have rapidly developed new ways of delivering services, and NHS, local government and other local services have worked together like never before to support local communities. But the pandemic has also exacerbated existing shortcomings. It has laid bare the weaknesses in a social care system that has been underfunded and overlooked for too long, placed an enormous strain on a health and care workforce already in crisis due to years of poor planning (NHS England and NHS Improvement 2020) and exposed deep and widening health inequalities, taking a disproportionate toll on the poorest communities and some ethnic minority groups.
The start of a new parliamentary session is an opportunity, not just to begin to restore services, but to use the learning from the pandemic to bring about change and renewal to deliver lasting improvements to the population’s health and wellbeing. It should also be an opportunity to learn the lessons from the response to the pandemic and ensure the country is ready to face future threats by preparing for a full public inquiry. We welcome the Prime Minister’s announcement that an inquiry will begin in spring 2022 but continue to believe it should be established as soon as practically possible.
The Queen’s Speech includes planned legislation to reform health and care in England, following the publication earlier this year of a health and social care White Paper (Department of Health and Social Care 2021). A new Health and Care Bill will signal a decisive shift away from the focus on competition that underpinned the coalition government’s 2012 reforms, to a new model of collaboration, partnership and integration.
At the heart of the changes is the establishment as statutory bodies of integrated care systems (ICSs) – partnerships that bring together NHS providers and commissioners with local authorities and other local partners. Other changes already consulted on and likely to be incorporated in the Bill include measures to reduce the role of competition in the NHS, remove the requirement for NHS services to be competitively tendered and formalise the merger of NHS England and NHS Improvement. The Bill is also likely to include proposals outlined in the White Paper to strengthen ministerial powers to direct NHS England and intervene in decisions about changes to local services.
The King’s Fund has long championed the development of integrated care to improve services for the increasing number of people with multiple long-term conditions. We therefore strongly support the ambition behind the Health and Care Bill and the shift in focus to collaboration in place of competition. While ICSs will drive the development of integrated care and lead the planning of services across wide geographical areas, much of the heavy lifting to join up services will happen at ‘place’ level – towns or districts within an ICS that often align with local authority boundaries. The White Paper did not include plans to introduce legislation to underpin arrangements for place-based working. We welcome this – it is important that a permissive approach to place-based arrangements survives the Bill’s passage through parliament and that places have the freedom to respond to the needs of their local populations, rather than following a one-size-fits-all statutory approach (Charles et al 2021).
While it is appropriate for the Secretary of State to have powers to intervene if needed, the establishment of NHS England is seen as one of the successes of the 2012 Health and Social Care Act and it is important to protect the clinical and operational independence of the NHS. Decisions about changes to local services must not be politicised and should continue to be determined locally in the interests of local communities. We will therefore study these aspects of the Bill carefully. It is also important to recognise the limitations of what can be achieved through legislation – while we welcome the focus on collaboration and partnership-working, successful implementation will be critically dependent on culture and behaviour change.
As the government’s manifesto recognised, the best way to improve the NHS and meet rising demand for health care is to invest in its most important asset – its people. Before the pandemic, staffing shortages were endemic, chronic excessive workloads commonplace and levels of stress, absenteeism and turnover worryingly high (NHS England and NHS Improvement 2020). Many staff will emerge from the past year physically and mentally exhausted and in need of time and support to recover. Yet the only proposal in the White Paper relating to the workforce is a new duty on the Secretary of State to publish a document every five years setting out roles and responsibilities for workforce planning and supply.
This is inadequate in the face of such a challenge. Alongside the Nuffield Trust and the Health Foundation, we are calling for a clause be included in the Bill to mandate Health Education England to publish annual, independently verified projections of future demand and supply of the health care workforce in England (Charlesworth et al 2021). This would be a powerful signal of intent. However, on its own, it would not be enough to tackle the workforce crisis and must go hand in hand with a fully funded workforce strategy that addresses staff shortages, boosts retention by improving working cultures and includes a renewed commitment to providing compassionate and inclusive leadership.
Adult social care reform
The social care system is not fit for purpose and is failing the people who rely on it, with high levels of unmet need and providers struggling to deliver the quality of care that older and disabled people have a right to expect (The King’s Fund 2021a). The Covid-19 pandemic has exacerbated many of these problems, increasing levels of unmet need and further destabilising an already fragile care provider market. Successive governments have failed to reform social care despite numerous White Papers, Green Papers and consultations. In his first speech as Prime Minister in 2019, Boris Johnson committed to ‘fix the crisis in social care once and for all’. However, the Queen’s Speech once again fell short of a meaningful commitment to take the action needed.
The government should set out a bold vision for social care that supports people to lead independent and fulfilling lives (Warren 2021). Immediate action is needed to address short-term funding pressures and stabilise the fragile provider market. To provide better care, the government needs to set out a roadmap to reform with the aim of delivering a simpler, fairer system that extends eligibility for publicly funded care, provides protection from the very high costs of care some people face and extends preventive support for people with lower levels of need (Dixon et al 2021). This should go hand in hand with wider reforms to improve the quality of care, improve the operation of the social care market and improve pay, conditions and training for the social care workforce.
Public health and inequalities
Following on from England’s poor record on life expectancy (Goldblatt and Raleigh 2019), Covid-19 has exposed the deep and widening inequalities that exist between different population groups and areas of the country. People who have been worst affected by the virus are generally those who had worse health outcomes before the pandemic, including people from ethnic minority communities and those living in poorer areas (Public Health England 2020). If the government is serious about its commitment to levelling up, it must address the growing gulf in health outcomes between our richest and poorest communities by developing a cross-government strategy to tackle health inequalities.
While it was not included in the Queen’s Speech, the government has also consulted on important reforms to the public health system that will see a new Office for Health Promotion established within government and the launch of a new UK Health Security Agency to protect the country against future health threats (Department of Health and Social Care 2021b). We welcome the commitment to a more coherent public health system and the stronger NHS focus on prevention and population health (The King’s Fund 20121b). These reforms should be accompanied by an increase in funding for local authority public health services which have seen their budgets cut significantly in recent years.
While there is much to welcome in the Queen’s Speech, the health and care system faces many challenges that cannot be addressed by the proposals set out by the government so far, including chronic staff shortages, deep health inequalities and an urgent need for long-term reform of social care. The NHS does not work in isolation and is closely connected to public health and social care. However, a clear overall vision for the three arms of the health and care system and how they work together is missing. We hope that the introduction of new legislation to parliament will provide an opportunity to discuss how to address this.
Charles A, Ewbank L, Naylor C, Walsh N, Murray R (2021). Developing place-based partnerships: the foundation of effective integrated care systems. London: The King’s Fund. Available at: www.kingsfund.org.uk/publications/place-based-partnerships-integrated-care-systems (accessed on 6 May 2021).
Charlesworth A, Edwards N, Murray R (2021). ‘NHS Bill must put a system in place to support better workforce planning’. The King’s Fund website. Available at: www.kingsfund.org.uk/publications/nhs-bill-must-support-better-workforce-planning-open-letter (accessed on 6 May 2021).
Department of Health and Social Care (2021a). Innovation and integration: working together to improve health and social care [online]. GOV.UK website. Available at: www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all (accessed on 13 May 2021).
Department of Health and Social Care (2021b). ‘Transforming the public health system: reforming the public health system for the challenges of our times’. GOV.UK website. Available at: www.gov.uk/government/publications/transforming-the-public-health-system/transforming-the-public-health-system-reforming-the-public-health-system-for-the-challenges-of-our-times (accessed on 6 May 2021).
Dixon J, Edwards N, Murray R (2021). ‘The Queen's Speech: The PM must set out a vision for social care and a timetable for reform’. Health Foundation website. Available at: www.health.org.uk/news-and-comment/news/the-queens-speech-the-pm-must-set-out-a-vision-for-social-care (accessed on 6 May 2021).
Goldblatt P, Raleigh V (2019). ‘Life expectancy in England: what's going on?’. The King’s Fund website. Available at: www.kingsfund.org.uk/publications/life-expectancy-england-bmj-article (accessed on 6 May 2021).
NHS England and NHS Improvement (2020). ‘NHS Staff Survey results’. NHS Staff Survey Results website. Available at: www.nhsstaffsurveyresults.com (accessed on 6 May 2021).
Oliver D (2020). ‘Tackling the Covid-19 outbreak: tales from the frontline’. Blog. The King’s Fund website. Available at: www.kingsfund.org.uk/blog/2020/04/covid-19-outbreak-tales-from-frontline (accessed on 6 May 2021).
Public Health England (2020). Covid-19: review of disparities in risks and outcomes [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 6 May 2021).
The King’s Fund (2021a). ‘Social care 360’. The King’s Fund website. Available at: www.kingsfund.org.uk/publications/social-care-360 (accessed on 6 May 2021).
The King’s Fund (2021b). ‘The King’s Fund’s response to plans for the future public health system in England’. The King’s Fund website. Available at: www.kingsfund.org.uk/publications/future-public-health-system-england (accessed on 6 May 2021).
Warren S (2021). ‘Making decisions about social care requires tough choices’. Blog. The King’s Fund website. Available at: www.kingsfund.org.uk/blog/2021/03/making-decisions-about-social-care-requires-tough-choices (accessed on 6 May 2021).