By Andy Bell
This week the Government published its plans to reform the NHS in a new white paper, Integration and Innovation: working together to improve health and social care for all. The proposals contained within it will lead to legislation that will change the way health services are planned and commissioned, creating new systems and structures and changing the rules for how organisations work together.
These changes will have a major impact on how mental health services are planned in future: on how much of a priority is given to mental health, who decides what gets commissioned and how the component parts of the health and care system connect.
As mental health support relies on effective joint working between health and care services, [the new duty to collaborate] has the potential to benefit people who currently find services fragmented, reactive and siloed.
Many of the changes set out in the white paper are likely to have significant benefits for mental health support. The white paper replaces a requirement that has been in place since 2013 for organisations to compete for NHS funding with a ‘duty to collaborate’. That duty includes requirements for NHS organisations to collaborate with each other and to collaborate with local councils. As mental health support relies on effective joint working between health and care services – as well as partners in housing, education and beyond – this has the potential to benefit people who currently find services fragmented, reactive and siloed.
The white paper proposes to make Integrated Care Systems (ICSs) statutory bodies which will have responsibility for using NHS funds in their areas. These new bodies, which cover populations of between one and three million each, will decide how health services are organised in their areas and how funds are spent, taking over from existing clinical commissioning groups.
Integrated Care Systems have potential risks and benefits for mental health support. Shifting the locus of decision-making from more localised CCGs to more remote ICSs risks severing links with communities and exacerbating the existing imbalance in power between the NHS and local authorities. And while ICSs will be allowed to delegate commissioning to more local groups within them, it is unclear as yet how far that will happen in practice and whether this will move decision-making closer to home.
Urgently needed reform of adult social care is once again postponed for another day, and plans to replace Public Health England’s health improvement functions remain a mystery.
The detail here is likely to be important. The white paper says, for example, that ICS boards will be required to ‘work closely’ with Health and Wellbeing Boards and to ‘have regard’ for local health and wellbeing strategies and needs assessments. But without any real accountability to local democratic structures, ICSs risk replaying the NHS’s long history of local bodies whose eyes are focused on upward accountability (to national government or executive agencies) with local voices left on the margins once again.
The white paper is as notable for what it doesn’t cover as for what it does. Urgently needed reform of adult social care is once again postponed for another day, and plans to replace Public Health England’s health improvement functions remain a mystery. Designing a new health and care system with these essential elements missing risks reinforcing again the pre-eminence of one part over the others. And where public health is mentioned in the white paper, it retreats to familiar language about “lifestyles [and] healthy behaviours” rather than the systemic and structural factors that determine our mental and physical health and that perpetuate inequalities.
As the white paper moves to legislation, Centre for Mental Health will scrutinise the Government’s proposals in detail and make the case for system change that increases accountability to communities, that embeds broad local partnerships, and that puts the public’s mental health first.