Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by integration correspondent, Sharon Brennan.

Next month, integrated care systems, whether in established or nascent form, are expected to put their final five-year system plans before NHS England and Improvement’s regional leads. The plans are expected to run from April 2020 to April 2025.

The NHSE long-term plan implementation framework, published in the summer, required these local documents to “align” with 10 principles, which included being developed “in conjunction with local authorities and with consideration of the need to integrate” with relevant council-commissioned services.

I am hearing from various senior people working in ICSs that this is presenting a significant challenge on the ground. One ICS senior manager told me councils were now involved in a “huge amount of day-to-day firefighting” because of their financial pressures. Rather than closer working, this has had the reverse effect of making the local authority “less involved” in ICS plans as it is focused on the immediate challenges ahead.

As a result, the ICS is still struggling to persuade the local council not to automatically tender services without thinking about how this affects the wider system agenda. My source said this is “unhelpful and takes work backwards” as these contracts, such as sexual health screening and school nurses, often cut across services health providers are trying to integrate.

A second issue is tension over issues which tarnished 2016 sustainability and transformation planning — council concerns the NHS is not genuinely engaging and being transparent; and NHS nervousness about sharing too much, including potentially controversial service change plans, with councillors.

Meanwhile, a leader in a different area of England asked how local authorities could develop an ICS when there is “great uncertainty” about any long-term funding solution to support growing demand for social care.

Through the summer and beyond, there have been warnings councils cannot continue to offer the services they do unless the funding crisis is resolved, as various interests seek to encourage the new administration in Whitehall to act. In May, the County Council Network, the umbrella group for county councils, warned local authorities will resort to providing the “bare minimum” of services. Research it had commissioned from PwC found councils faced a £52bn funding black hole over the next six years — roughly the period these system plans are expected to cover. 

Meanwhile, the Health Foundation has noted, in the absence of additional funding, the money available for adult social care will rise at an average rate of 1.4 per cent a year in real terms — much lower than the 3.4 per cent a year the government has committed to the NHS and far below rising demand of 3.6 per cent a year. It has also confirmed the NHS is effectively poaching staff from social care providers, as NHS wages are slowly beginning to rise while those in social care stagnate. These disparities are likely to make integration trickier as staffing and funding gaps widen.

One source involved in the local long-term plan process explained that — as is familiar with such exercises — they were seen by many councils as “just an NHS plan that the local areas have to get over the line”. The source added: “Unlike the NHS, councils wouldn’t just write any number [they cannot realistically achieve] in a plan as we would lose our jobs over that.”

With Britain now heading to the polls on 12 December and Brexit delayed — again — until next year, the arrival of firm proposals for social care funding reform seems no closer. Although the Conservative Queen’s Speech promised to “bring forward substantive proposals [including] setting out legislative requirements”, any detail of these has been glaringly absent. 

Meanwhile, a Labour election victory would require a major reworking of the policy, the party having recently promised free personal care to older people (notably not solving the problems working-age disabled people face accessing domestic care).

Without any national direction on the funding available for social care, ICS planners face a conundrum that seems to necessitate a fudging of their local implementation plans. One leader told me: “Things could get fixed to meet [NHSE/I’s] timeline nationally and then retrofitted later to fit in social care after [plans are approved].” So expect the final plans to be widely variant on social care integration.

Some areas will have local authorities much more willingly engaged in developing ICS policy, even if they don’t yet know what funding they can commit. Others will have councils stepping back from engagement as day-to-day demands overwhelm them.

What is clear is the longer social care funding policy remains unresolved, the harder it will be for systems to continue to drive down delayed discharges of care, let alone try and turnaround rising accident and emergency attendance and emergency admissions by pushing the prevention agenda — for which councils have a lot of the responsibility, and which is so important to the NHS staying within its own financial envelope.