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Work the System: The Simple Mechanics of Making More & Working Less -- 3rd Edition

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About this deal

These proposals focus on enhancing public confidence by ensuring that we have the right framework for oversight of our health system, that national bodies are streamlined, with clear roles and responsibilities, and that the public and Parliament can hold decision makers to account.

But no one recognises more than does the government, and certainly no one recognises more than I do, that no legislation, however wisely conceived and however efficiently embodied in an Act of Parliament, can ever give the public a great health service unless the people who administer it want to do it and are enthusiastic in doing it. We know there has been excellent progress in some areas in making a reality of integrated care. We also know that this has sometimes been in spite of the systems we ask people to work within, and that it is far from universally true that integration is proceeding in step with the needs and lives of the people we serve. We have therefore – with the help of NHS England’s work following the Long Term Plan – identified several further changes to reinforce or enable integration. Details of the NHS’s proposals, which we have bolstered with an additional duty to collaborate, are set out below. Duty to collaborate The Department of Health and Social Care’s paper, busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in the health and care system in England, sets out the government’s strategy for reducing excess bureaucracy. These actions are being taken forward through a variety of different projects, some led by the department, some by regulators and some by other bodies across the health and care system. Whilst we can do a lot to reduce bureaucracy through changing processes and culture, the Department’s engagement demonstrated that a lot of bureaucracy is also generated by the legislation which in some places is no longer fit for purpose and we therefore want to use this opportunity to amend legislation to resolve these issues. Each year the government publishes the NHS mandate, a document which sets out the objectives which NHS England should seek to achieve. The NHS mandate is intended to set strategic direction for the NHS by setting out the top priorities that the government expects NHS England to focus on delivering. These objectives are carried through to NHS England’s planning guidance. On current timeframes, and subject to Parliamentary business and successful passage, our plan is that these proposals for health and care reform will start to be implemented in 2022. We will continue to engage with stakeholders across the health and care systems, our arm’s length bodies and the devolved administrations on the detail of these proposals as they progress. We will also continue to work across government to ensure that the right systems and processes are in place that work for all, recognising the interdependencies between health and other social determinants. Annex A: Proposals for legislation Working together and supporting integration proposals

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While LETBs operate only in England, we will work with devolved administrations should this proposal have any UK-wide impact. There are, then, 2 forms of integration which will be underpinned by the legislation: integration within the NHS to remove some of the cumbersome boundaries to collaboration and to make working together an organising principle; and greater collaboration between the NHS and local government, as well as wider delivery partners, to deliver improved outcomes to health and wellbeing for local people. Medical care advancements and technological innovations. As medical care advances there are more treatments available and more conditions can be treated This is no ordinary moment. We have seen collaboration across health and social care at a pace and scale unimaginable even a little over a year ago. The NHS and social care providers have delivered outstanding care to those in need while at the same time radically changing ways of working, reducing bureaucracy and becoming more integrated. New teams have been built, adoption of new technology has been accelerated, new working-cultures developed, and new approaches to solving difficult problems pursued. As a result, NHS capacity grew; new hospitals were built in just a matter of days; and new ways of treating patients have become the norm. As we look towards the future and to the recovery of our society, our health and care system will continue to be central to our national wellbeing and prosperity in the years ahead.

give NHS England the ability to joint commission its direct commissioning functions with more than one ICS Board, allowing services to be arranged for their combined populationsCOVID-19 response. As of 9 February 2021, the UK has vaccinated 12.6 million people. In the early stages of the response, the NHS COVID-19 Data Store was established, which safely brought together accurate, real-time information necessary to inform decisions in response to the current pandemic in England We are proposing to establish statutory ICSs, made up of an ICS NHS Body and an ICS Health and Care Partnership (together referred to as the ICS), to strengthen the decision-making authority of the system leadership and to embed accountability for system performance into the NHS accountability structure. This dual structure recognises that there are 2 forms of integration which will be underpinned by the legislation: the integration within the NHS to remove some of the cumbersome barriers to collaboration and to make working together across the NHS an organising principle; and the integration between the NHS and others, principally local authorities, to deliver improved outcomes to health and wellbeing for local people. COVID-19 has demonstrated the importance of different parts of the health and care system working together in the best interests of the public and patients. This has been something that organisations in the health and care system have been increasingly working towards over the past few years, despite the barriers in legislation which sometimes make it difficult to do so. We propose to implement NHS England’s recommendations and legislate to support integration, both within the health service, and between the health service and local government, with its statutory responsibilities for public health and social care.

These proposals focus on stripping out needless bureaucracy, turning effective innovations and bureaucracy busting into meaningful improvements for everyone, learning from the innovations during COVID-19. Safety. The UK is recognised internationally as a world-leader in driving the patient safety agenda in healthcare This proposal will remove the duty to set NHS England’s capital and revenue resource limits in the mandate itself. Instead, these limits will continue to be set within the annual financial directions that are routinely published, and which will, in future, also be laid in Parliament. The direction set in the mandate will continue to be closely aligned to the capital and resource spending limits set through financial directions. The Secretary of State will retain their duty to consult NHS England before setting a mandate. The original set of national NHS bodies has already altered in form and purpose, and in the proposed legislation, we intend to continue the work already undertaken to formally bring together NHS England and NHS Improvement into a single legal organisation.

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enable NHS England to delegate or transfer the commissioning of certain specialised services to ICSs singly or jointly, or for NHS England to jointly commission these services with ICSs if these functions are considered suitable for delegation or joint commissioning subject to certain safeguards. Specialised commissioning policy and service specifications will continue to be led at a national level ensuring patients have equal access to services across the country We are also bringing forward several measures to improve accountability in the system in a way that will empower organisations and give the public the confidence that they are receiving the best care from their health and care system, every time they interact with it. The de facto development in recent years of a strongly supportive national NHS body in the form of a merged NHS England and NHS Improvement will be placed on a statutory footing and will be designated as NHS England. This will be complemented by enhanced powers of direction for the government over the newly merged body which will support great collaboration, information sharing and aligned responsibility and accountability. In addition, we will legislate to further ensure the NHS is able to respond to changes and external challenges with agility as needed. Measures will include reforms to the mandate to NHS England to allow for more flexibility of timing; the power to transfer functions between arm’s length bodies and the removal of time limits on special health authorities. An improved level of accountability will also be introduced within social care, with a new assurance framework allowing greater oversight of local authority delivery of care, and improved data collection allowing us to better understand capacity and risk in the social care system. Our measures recognise this, and we therefore plan to introduce greater clarity in the responsibility for workforce planning and a clear line of accountability for service reconfigurations with a power for ministers to determine service reconfigurations earlier in the process than is presently possible. Additional measures

Joint appointments of executive directors can help to foster joint decision making, enhance local leadership and improve the delivery of integrated care. They can also help to reduce management costs and engender a culture of collective responsibility across organisations. Over the last 2 years, we have seen NHS England and NHS Improvement come together to work effectively as a single organisation. We have seen clear benefits from them working in practice as one organisation providing national leadership: speaking with one voice, setting clearer and more consistent expectations for providers, commissioners and local health systems; removing unnecessary duplication; using collective resources more efficiently and effectively to support local health systems and ultimately making better use of public money. NHS England will need to keep the guidance under review, and if substantial changes to it are considered, they will need to consult appropriate organisations before the revision is published. Data sharing It will also support the Secretary of State to set clear direction in a more agile way, and to do so formally alongside the strong and effective informal arrangements for working together that have evolved between the Department and NHS England in recent years. Alongside the creation of statutory ICSs, we intend to introduce a new duty to promote collaboration across the healthcare, public health and social care system. Many existing duties on health and care organisations emphasise the role of the individual organisation and its own interests. We want to rebalance these duties to reflect the need for all health and care organisations to work collaboratively. When collaboration works well it leads to better outcomes for people, for example a successful early intervention can lead to people living independently and in their own homes for longer.In practice, we recognise that ICSs will have to develop effective and legitimate decision-making processes, and we are giving ICS NHS bodies and ICS Health and Care Partnership the flexibility to develop processes and structures which work most effectively for them. We also know that we need to support staff during organisational change by minimising uncertainty and limiting employment changes. We are therefore seeking to provide stability of employment and will work with NHSE and staff representatives to manage this process. introduce powers for the Secretary of State for Health and Social Care to require data from all registered adult social care providers about all services they provide, whether funded by local authorities or privately by individuals (discussed further in the adult social care proposals); and require data from private providers of health care These reforms will only apply to the arrangement of healthcare services – including public health services whether commissioned solely by a local authority or jointly by the local authority and NHS as part of a S75 agreement. The procurement of non-clinical services, such as professional services or clinical consumables, will remain subject to Cabinet Office public procurement rules. National tariff In a typical 24-hour period, the NHS in England will see 1 million patients in GP appointments and carry out over 26,000 operations. In the social care system, local authorities are supporting almost 150,000 older people and over 40,000 young people in care homes as well as over 440,000 people in the community. Councils received 1.9m requests for adult social care support in 2019/20 – equivalent to 5,290 requests for support per day. Behind those numbers there are many stories of hope, vulnerability, care and healing; and of health and care services that have empowered and helped people to live fulfilling lives. These stories are the work of the dedicated staff who make our NHS and our care system what it is, and the real experiences of the people behind the statistics.

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