Integration of Primary and Community Care Committee report: ‘Patients at the centre: Integrating primary and community care’

On 9 May 2024, the House of Lords is scheduled to debate the House of Lords Integration of Primary and Community Care Committee’s report ‘Patients at the centre: Integrating primary and community care’ (15 December 2023, HL Paper 18 of session 2023–24).

1. Background

Primary care services are defined by NHS England as the first point of contact in the healthcare system and include general practice, pharmacy, dental and optometry services. In contrast, community health services are mainly delivered in people’s homes, in addition to community hospitals, intermediate care facilities, clinics and schools. They cover a wide range of services and provide care for people from birth to end of life. In February 2022, the government published a white paper on health and social care integration, proposing greater integration of primary and community care services.^[1] Further information on primary and community care and the government’s policies on increasing the integration of these services is provided in the House of Lords Library briefing ‘Primary and community care: Improving patient outcomes’ (10 August 2022).

In April 2022, the Health and Care Act 2022 received royal assent. This act gave integrated care systems (ICSs) statutory powers and responsibilities for the allocation of NHS resources and the health of the population in their local areas. ICSs consist of two components: Integrated Care Boards (ICBs), which are responsible for the planning and funding of most NHS services in their area, and Integrated Care Partnerships (ICPs).^[2] ICPs are statutory committees which include local government, voluntary organisations and NHS bodies. They are responsible for establishing integrated care strategies for their individual area in order to identify local healthcare priorities and coordinate services.^[3]

2. Committee findings and recommendations

In March 2023, the House of Lords Integration of Primary and Community Care Committee launched an inquiry into the delivery of integrated primary and community care services.^[4] Specifically, the committee considered the challenges of adapting existing healthcare structures in order to deliver more integrated services and the barriers preventing greater integration. It also considered the impact of recent changes to the structure of local health services, including the establishment of ICSs.

The committee published its report in December 2023.^[5] The committee concluded that, while some progress had been made, the NHS had so far failed to achieve the full integration of primary and community care services. It argued poorly coordinated care had the potential to undermine the quality of a patient’s experience with NHS treatment and could have “profound consequences for their long-term health”.^[6] The chair of the committee, Baroness Pitkeathley (Labour), said the establishment of more joined-up care and a greater focus on preventative treatments were necessary:

[…] if the NHS is going to be able to address the problems posed by the growing number of people in our society with multiple health issues which need complex and continuous care.^[7]

The committee identified four obstacles preventing the further integration of primary and secondary community care services and made recommendations on how to overcome them:

• Structure and organisation: The committee concluded professional relationships between services were fundamental in order to achieve further integration. It said improving these inter-service relationships had proved difficult. It said there were signs that new ICSs established under the Health and Care Act 2022 were engendering a “collaborative” ethos. The committee argued ICSs should be given time to mature. It recommended the Department of Health and Social Care (DHSC) should evaluate ICS structures before implementing any major health service reforms. It also recommended the membership of ICBs should be expanded to include elected officials.
• Contracts and funding: The committee argued the way in which contracts are allocated and funding awarded in the NHS needed to be simplified and made more flexible in order to encourage integrated, multi-disciplinary working. The committee made serval recommendations for how to achieve this, including aligning primary and community care contracts in a way which incentivised integrated working. The committee also recommended the government should explore different ownership models for GP practices in order to facilitate the co-location of GP and other community services, including social care workers, community nurses and other community clinicians such as podiatrists.
• Data sharing: The committee concluded better coordination of NHS data across different services was essential to achieving fully integrated care. It recommended the DHSC should issue guidance on standardising data sharing between healthcare professionals. It also noted clinicians were often hesitant to share data because of the perceived risk of contravening the general data protection regulation (GDPR) and other data protection laws. It recommended the government should clarify guidance on data sharing.
• Workforce and training: The committee concluded efforts to improve the coordination of services were being hampered by staff shortages. It recommended the integration of services should be included in initial clinical training and clinicians should be introduced to the work of other services through job rotation. It also recommended social care needs should be included in the NHS’s ‘Long term workforce plan’ in order to increase the number of trained social carers available.

3. Government response

The government published its response to the committee’s report in March 2024.^[8] The government welcomed the committee’s report and said it was committed to increasing the integration of primary and community care services, including by working with ICSs. The government said the DHSC had commissioned an independent research study of the implementation of ICSs under the Health and Care Act 2022. The post-implementation review of the 2022 act was launched in November 2023 and is scheduled to end in October 2026.^[9] On the specific recommendation concerning the membership of ICBs, the government said it planned to retain the existing ban on elected politicians chairing these boards. It argued the ICS governance structures already ensured local authorities had input on how local services are run.

The government said national primary care contracts and the NHS standard contract were both being kept under review and it would “consider the committee’s recommendations carefully” as part of this.^[10] Responding to the committee’s recommendation regarding the ownership models of GP practices, the government said it recognised the advantages offered by the co-location of services. It did not commit to conducting a review as recommended by the committee. However, it said NHS England would continue to explore different ways in which services can be provided, including NHS-owned multi-disciplinary hubs.

The government said work was already underway to improve standards for data collection and sharing across NHS England. It said NHS England was “currently working on how to make clear which standards are ‘musts’ for the sector and how these can be enforced”.^[11] It also said it planned to include changes to section 250 of the Health and Social Care Act 2012 in the Data Protection and Digital Information Bill 2023–24 in order to apply technical standards to suppliers of IT systems and services that are equivalent to those applied to health and social care providers. Clause 145 and schedule 14 of the Data Protection and Digital Information Bill (as amended at committee stage in the House of Lords) includes amendments to section 250 of the 2012 act.^[12] On the issue of data protection, the government said it had published an information governance portal which is intended to act as a single source of guidance for the health and social care system.^[13]

Responding to the committee’s recommendations concerning clinical training, the government said the content and delivery of training of healthcare professionals was the responsibility of independent statutory regulatory bodies including the General Medical Council (GMC) and the Nursing and Midwifery Council. It said existing guidance from the GMC encouraged medical students to experience a variety of placements.^[14] It also said an ‘enhanced’ program of training was offered by NHS England to staff as part of their professional development to improve generalist skills and support their work across different areas within their local ICS. The government also said it was investing £250mn over the next two years to improve the adult social care workforce, and highlighted that it had established a new career structure entitled the ‘care workforce pathway’, launched in January 2024.^[15]

4. Recent government statements

On 18 April 2024, Lord Swire (Conservative) tabled a written question asking the government what progress it had made on integrating social care and the NHS.^[16] Parliamentary Under Secretary of State at the Department of Health and Social Care Lord Markham responded on 25 April 2024. He said all ICPs had now published integrated care strategies. On the issue of integration more generally, Lord Markham said:

The integration of health and social care is often best achieved through collaboration across smaller geographies within integrated care systems called ‘places’. Since the Health and Care Act 2022, we have seen good progress in the development of place-based arrangements to integrate health and social care. In October 2023, we published our ‘Shared outcomes toolkit’ designed to help place-based partnerships develop shared outcomes as a powerful means of promoting integrated working and joined-up care. We also issued a call for evidence as part of our review of section 75 of the NHS Act 2006, which permits local authorities and National Health Service bodies to pool budgets, enabling joint commissioning and the commissioning of integrated services. The findings of this review will be shared in due course.^[17]

5. Read more

• House of Lords Library, ‘Long-term sustainability of the NHS: Options for systems and funding’, 21 March 2024
• House of Lords Library, ‘The 75th anniversary of the NHS: How is it doing?’, 23 November 2023
• King’s Fund, ‘Making care closer to home a reality’, 13 February 2024

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Photo by National Cancer Institute on Unsplash.