On Monday 22 November the Health and Care Bill passed the House of Commons. As I wrote this blog, the Bill is currently at the second reading stage in the House of Lords. The Bill aims to provide the legislative framework that will lead to more collaboration between NHS providers and commissioners. This will be done through Integrated care systems (ICS’s). These ICS’s will be made up of two parts: Integrated Care Boards and Integrated Care Partnerships. The ICS’s will also be expected to ensure more of a focus on improving health rather than simply providing health care services.
I am broadly supportive of some of the elements of the Bill and what it is trying to achieve. Having seen some of the challenges caused by competitive commissioning and “fragmentation” of services, a collaboration of services will be a positive change for patients and staff. However, there are two elements of the Bill that gives me cause for concern: tackling ethnic health inequalities and paying for social care.
Tackling ethnic health inequalities
According to the draft bill, each integrated care board must, in the exercise of its functions, have regard to the need to (a) reduce inequalities between patients with respect to their ability to access health services, and (b) reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services. Integrated care boards must prepare a plan setting out how they propose to exercise their functions in the next five years with regards to reducing inequalities as described above. They will also have to prepare an “annual report” on how it has discharged its functions in the previous financial year with regards to reducing inequalities.
We know that people from an ethnic minority background still face too “many injustices” in the NHS, both as staff and as patients. These ethnic inequalities were further “starkly exposed” by the Covid-19 pandemic. While I welcome having inequality built into the Bill, it was disappointing to see that tackling ethnic health inequalities was not mentioned separately. This would have given clear direction/instruction to the health system in general and ICS’s to pay attention to ethnic health inequalities. In addition, as recommended by the recently published paper by the Race and Health Observatory, “there should also be an enabling accountability framework that puts inequalities on an equal footing with the most important performance metrics and encourages innovation and experimentation to reflect the complex nature of inequalities”.
Given the critical role that ICS’s will have in tackling inequalities, the lack of ethnic diversity in ICS leadership is concerning. As of 3 December 2021, 37 of the 42 ICS leads had been confirmed. Only one (2.7%) was from an ethnic minority background. By comparison, data shows that as at 31 March 2021, ethnic minorities represented 22.2% of the workforce. The recruitment of ICS leads presented an opportunity to upend the lack of diversity in trusts and CCG’s leadership roles highlighted in the 2020 WRES report. The lack of diversity in leadership means not only missing out on the benefits of ethnic diversity, but can also lead to groupthink and a lack of innovation. The current health and social care challenges require new ideas, fresh approaches and different ways of doing things. Having diversity in leadership can help with this.
Paying for social care
The other big concern I have in the Health and Social Care Bill is the change in the cap or the amount people pay for their social care costs. The Bill will introduce a cap of £84 000 on the care cost people will have to pay in their lifetime. As warned by other people, the move to count only individual payments towards the cap, and not local authority contributions, would cost poorer recipients more in assets than the wealthy.
We know that as demonstrated in the Runnymede research, ethnic minorities are “more likely to be in the lowest paid work, and to be living in poverty”, “generally have much lower levels of savings or assets than White British people”, “have fewer savings”, and “much less likely to inherit property or financial assets from family members”. This is compounded by the fact that people from ethnic minority backgrounds report fair or bad health at a much younger age. These factors combined point to ethnic minorities having to get rid of a larger proportion of their assets at a much younger age to cover social care costs. This will then result in the poverty cycle starting all over again as they will have no assets or wealth to pass on to their children and grandchildren.
The presence of the NHS Race and Health Observatory and the Office for Health Improvement and Disparities shows a commitment to tackling ethnic health inequalities. However, the government must work closely with these organisations and key stakeholders to make sure that key policies such as the Health and Care Bill are used as leverage to reduce ethnic health inequalities. This includes having the right leadership, specific ambitions about tackling ethnic health inequalities, dedicated long term resources and putting the appropriate accountability framework in place.
Owen Chinembiri is the Senior Implementation Lead at the NHS Race and Health Observatory.