NHS long-term plan: legislative proposals inquiry: Written submission to the Health and Social Care Committee

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Our response to the Health and Social Care Committee's legislative proposals inquiry focuses on the implications of the proposals for possible changes to legislation, both individually and in aggregate. 

We support the spirit of these proposals, which are intended to make it easier for local NHS bodies to work together to improve the health and care of their populations.  Our view is that a wholesale revisiting of the legislative framework is neither achievable nor desirable at present and we therefore welcome the targeted nature of these proposals. 

Key messages

  • The King’s Fund supports the spirit of the proposed changes to NHS legislation. We have long made the case that the NHS and its partners need to work differently by breaking down barriers between services to improve care for patients and give greater priority to promoting population health. This will require those working within the health and care system to collaborate across organisational boundaries.
  • Progress in joining up local services has been made in spite of the current legislative framework rather than because of it. This has been achieved using workarounds, but these are inherently complex and rest on local leaders being willing to work through these complications together. If the intention is to further integrate services, then legislative changes will be needed sooner rather than later to support progress and to bring the statutory framework into line with changes to local services.
  • The form and function of integrated systems is evolving locally and there is wide variation in their maturity and effectiveness. At this point, legislative changes must therefore strike a balance between providing sufficient clarity and creating enabling flexibilities without inhibiting progress by over-specifying structures. A wholesale revisiting of the legislative framework would not be desirable at present and we therefore welcome the targeted nature of these proposals.
  • On the whole, the proposals take a pragmatic approach to addressing barriers to integration, and many stem directly from the experience of local systems. We would expect many of the proposed flexibilities to be helpful to advanced integrated systems looking to progress and streamline their collaborative working arrangements.
  • It is important to recognise that, if enacted, the proposals would create an interim set of enabling flexibilities rather than a definitive blueprint. There is no doubt that further legislation will be needed in due course to create more coherence across the statutory framework as a whole, if a single model for NHS structures and governance is the ultimate intention.
  • While we appreciate that these proposals are intended to be targeted, there are some notable omissions that we believe need to be addressed. These include clarifying the role of the Care Quality Commission (CQC) in reviewing systems as well as organisations, and how these proposals relate to the statutory role of health and wellbeing boards.
  • The proposals leave significant questions about the future direction of travel for the health service. It is too early to set out the answers to all these questions in legislation, but a clearer accompanying narrative is needed to ensure a transparent and shared understanding of where the proposals are intended to lead.
  • In particular, we are disappointed that the role of local government does not appear to be central to the narrative set out in the proposals or in the NHS long-term plan. In our view, the objectives of integrated care cannot be realised without the full and meaningful involvement of local government. In addition, the proposals underplay the important role of the voluntary and community sector.
  • It is not clear what levers for quality and improvement the national NHS bodies intend to put in place in lieu of the system of markets and organisational autonomy that is now being unpicked. There is a risk that in the absence of other levers, these proposals reinforce greater central control over the running of local services.
  • Finally, the scale and reach of these proposals should not be underestimated; they amount to a major set of changes reversing many of the principles underpinning the 2012 Health and Social Care Act and the policies that came before it. Their passage is unlikely to be straightforward and the NHS cannot put progress on hold while it waits for them to be enacted. For the time being, local systems need to continue their efforts to collaborate more closely within existing frameworks.

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