Labour has been in office for 21 months. But in a weird way, this April marks the start of its stewardship of England’s public services. As the new financial year kicks in, last summer’s spending review takes effect and critical government reviews start to be implemented.

In the case of adult social care, two major reviews set the direction. First, the Fair Funding review of local government finance starts the slow process of aligning spending power and population need. It is accompanied by a culling of ringfenced grants; a local outcomes framework to track progress on the government’s top priorities; and a new set of outcomes and expectations for adult social care. The latter ask councils to prioritise improved quality, more choice and control, and joining-up health and care services at neighbourhood level.

Second, the 10 year health plan makes a commitment to shift ‘from hospital to community’ and promises the creation of the ‘neighbourhood health service’. The detail was set out last week by the Department of Health and Social Care in its neighbourhood health framework. The document covers a huge amount, but from the perspective of adult social care the key developments are integrated neighbourhood teams to serve high-needs population groups; and the redoubling of efforts to apply community interventions to reduce the use of hospital.

Together these frameworks are intended to provide a strategic steer for local health and social care commissioners to integrate planning and delivery, remodel services and improve outcomes, over the three-year life of the spending review. But it is telling that there are two processes not one, for the NHS and adult social care, even when the aim is integration. Although they have strong overlaps, the two are not identical in form nor content.

Rival goals for integrated care

To start, the government has set different performance objectives for joining-up for different parts of the system. The local government outcomes framework, the neighbourhood health framework and Better Care Fund grant conditions each set goals: for councils, for the NHS and the two combined (see figure 1). But the goals are not the same.

Figure 1: Government goals for joined-up health and care that don’t join up. Outcomes specified for local government, the NHS and joint commissioning are overlapping but not identical

These performance measures basically address the same group of people with high health and support needs, and they require overlapping, integrated solutions. Surely it would make more sense for ministers to set a single set of measures and targets for integrated care across health and social care?

If the government can’t set joined-up goals, even for joining-up, there is still work to do.

Parallel approaches

The neighbourhood health framework is still essentially a document telling the NHS what to do. There are lists of targets and actions that are compulsory for the health service – and then suggestions for other things local areas might also do together beyond healthcare. For directors of adult social services, it must feel like reading a book over someone else’s shoulder. The main audience is NHS Integrated Care Boards, which are becoming more distant from local authorities as they scale-up. Council-led Health and Wellbeing Boards are to be involved, especially in developing integrated neighbourhood teams, but they are mainly overseeing the local, discretionary part of the agenda.

I think there are two things going on here. First, ministers have a laser-like focus on NHS improvement that is visible to lots of voters. Everything in the neighbourhood health plan leads back to that starting point. When holistic, system-wide action is embraced for high-needs groups, it is because it is needed to solve wider healthcare problems and restore public confidence in the NHS.

Second, in a spirit of devolution, there is a coyness about telling local government what to do. Health-related targets are mandated from the centre. By contrast, social care measures are introduced to inform local target-setting, peer-to-peer support and (for the first time in years) an occasional light-touch conversation with the centre. I can imagine that adult social care departments will be far more focused on the verdict of CQC assessments than the gentle ‘asks’ the government is making here.

With two systems that need to transform in parallel and integrate, such localist niceties are getting in the way. Across both health and care, more local autonomy is needed but also national direction and support: ministers should specify the ‘what’ and localities the ‘how’.

The National Care Service blueprint I developed in 2023 would help address both these issues. With the brand of a ‘national service’ ministers would have more political skin in the game with respect to social care; and the mandate and machinery of a ‘national service’ would provide the monitoring, leadership and support required to help care improve.

DHSC is at least trying

In fairness to the government, it could have been a lot worse – there is more coherence and integration between the different plans than many in social care had feared. Last summer’s 10 year health plan was very much a strategy for the NHS not the entire health and care economy. And Autumn’s NHS medium term planning framework managed to mention social care just once.

The neighbourhood health framework is a big improvement. Although it mainly speaks to the NHS, it includes social care needs and solutions, and it places local authorities on a near-equal footing in terms of strategy and commissioning. You can tell that officials have tried hard to weave in local government and social care across the plan. Proposals from care sector leaders (that I helped to write)1 have clearly been considered.

The document is particularly good with respect to older people.2 It includes commitments to supporting people with frailty and dementia, and those who are living in care homes, housebound or near the end of life. When I worked at Age UK, we’d have been bowled over to see this centre-stage in a government health strategy. 15 years later, financial necessity has driven the NHS to see prevention-focused geriatric care as its core business. And healthcare leaders have recognised that they can only improve older people’s health outcomes, and reduce demand for acute care, by targeting independence and wellbeing through social care and other local government services.

Going further

But deeper integration is still needed. The statement I helped care sector leaders write looked at the contribution of social care to the whole of the neighbourhood health agenda. It showed: (1) how social care professionals bring essential skills to person-centred neighbourhood care; (2) how social care prevents health needs; and (3) how social care is a partner in delivering healthcare. The last point is often forgotten but these days care assistants are the unacknowledged (and often unfunded) frontline of clinical care.

So what should happen? In the paper we suggested that local systems should embrace joint commissioning across a wider range of activities, align operational footprints, work together on data and technology, maximise use of direct payments and personal health budgets, create joint carers’ registers and integrated carer support, and embed housing at the heart of the planning and provision of neighbourhood health. They should also treat the local health and care workforces as one, with respect to building joint neighbourhood teams; supporting clinical roles and clinical tasks in social care (including at independent providers); and ensuring local leaders work and train together.

Across England there is huge enthusiasm for neighbourhood-level integration among local public service leaders. And a great deal can be done through local leadership and learning. But more national support would also help. So to conclude, here are eight ideas for national policies (suggested in the position paper) that can help bring joint neighbourhood health and care to life:

1. Extend the planned NHS 10 year workforce plan to healthcare professionals working in social care

2. Develop and implement the ‘modern service framework’ for frailty and dementia jointly across the NHS and adult social care

3. Integrate approaches to measurement and performance, with areas held account for a limited, shared set of strategic outcomes

4. Build democratic accountability and oversight into the NHS at every level

5. Include adult social care in the NHS digital strategy, with a joint approach to the development of the NHS App, the single care record and adoption of care technologies

6. Expand high-quality housing with care developments nationwide, by revising planning and funding policies

7. Update legislation and policy on joint commissioning and pooled budgets

8. Implement a cross-government carers strategy with joined-up support and protections across NHS, adult social care, social security and employment