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Integration White Paper

Volume 708: debated on Wednesday 9 February 2022

With permission, I would like to make a statement on the integration White Paper.

The covid-19 pandemic has been a living example of the importance of working together as one. Whether it is the extraordinary success of the vaccination programme or the work to identify and protect the most vulnerable, we were at our best when we were working across traditional boundaries towards a common goal. We must learn the lessons of the pandemic and channel this spirit of collaboration.

Although huge progress has been made in bringing together our health and care services and local government, our system often remains fragmented and too often fails to deliver joined-up services that meet people’s needs. Thanks to incredible advances in health and care, people are enjoying longer life expectancies, but may be living with more complex needs for longer. Navigating a complex health and care system to meet those needs can be hard, especially when services are often funded, managed and delivered separately. People too often find that they are having to force services to work together, rather than experiencing a seamless, joined-up health and care journey.

If we are to succeed in our goals of levelling up our nation, we must keep working to make integrated health and care a reality across England. Today, we are publishing the integration White Paper, which shows how we will get there. It is the next step in our ambitious programme of reform, building on the Health and Care Bill and the social care reform White Paper, which this Government introduced to the House in December.

This White Paper has been shaped by the real-world experience of people, as well as by that of nurses, care workers and doctors on the frontline, drawing on some of the great examples of collaborative working we have seen, particularly during the pandemic. It will make health and care systems fit for the future, boost the health of local communities and make it easier to access health and care services. It is a plan with people and outcomes at its heart—no more endless form filling, no impenetrable processes and no more bureaucracy that sees too many people getting lost in the system and not receiving the care they need.

First, we will ensure strong leadership and accountability, which is critical to delivering integration. Local leaders have a unique relationship with the people they serve. Our plans will bring together local leaders to deliver on shared outcomes, all in the best interests of their local communities, and encourage local arrangements that provide clarity over health and care services in each area, including aligning and pooling budgets. This arrangement has already been successfully adopted in several local areas. We have suggested a model that meets these criteria, and we expect areas to develop appropriate arrangements by spring of next year. Local NHS and local authority leaders will be empowered to deliver against these outcomes, and will be accountable for delivery and performance against them. They will be supported by a new national leadership programme addressing the skills required to deliver effective system transformation and strong local collaboration.

Integration supports transparency, and joining up NHS and local authority data means that we can provide local people with better insights about how their area’s health and care services are performing. With access to more information, they will be more empowered to make decisions about where and how they access care. There will be a new single accountable person for delivery of a shared health and care plan at local level. In practice, that could mean an individual with a dual role across health and care or a single lead for a place-based arrangement.

Secondly, we will do more to join up care. At the moment, too many people are bounced around the system or have to tell their story multiple times to different professionals to get the care that they need, which is frustrating for people and frontline workers alike. There are so many opportunities here. Closer working between primary and secondary care can allow care that is closer to home, keeping people healthy and independent for longer, and closer working between mental health and social care services can reduce crisis admissions and improve the quality of life for those living with mental illness. The White Paper sets out how we will get there, using the power of data to give local leaders the information that they need to establish new, joined-up services to tackle the issues facing their communities.

Thirdly, we will make the best use of the huge advances in digital and data. We have seen throughout the pandemic how digital tools can empower people to look after their health and take greater control of their care—for instance, through the NHS app or remote monitoring technologies. Where several organisations are involved in one person’s care, there is a real opportunity to bring together data safely to create a seamless and joined-up experience. The White Paper reiterates our commitment to having shared records in place for all people by 2024, providing local people with a single, functional health and care record that everyone involved in care can access in a secure way. That will mean every professional having access to the key facts relating to a person’s condition, such as their diagnoses and medications. That will improve care, too, with professionals able to make care plans in full knowledge of the facts.

We have seen a rapid expansion of digital channels in primary and secondary care services in recent years, but there is plenty more that we can do. This year, one million people will be supported by digitally enabled care pathways in the comfort of their home. The White Paper sets out how we will open up even more ways for people to access health and adult social care services remotely. We will also support digital transformation by formally recognising the digital data and technology profession within the NHS “Agenda for Change”, and including basic digital, data and technology skills in the training of all health and care staff. Integrated care systems will be tasked with developing digital investment plans so that we can ensure that digital capability is strong right across the board. That means data flowing seamlessly across all care settings, with technology transforming care so that it is personalised to the patient.

Finally, the White Paper shows the part that the workforce can play. The health and care workforce is one of the biggest assets that we have, and we want to make it easier for people working in health and care to feel confident in how the system works together in the best interests of those they care for and to feel empowered to progress their careers across the health and care family. To drive that, integrated care systems will support joint health and care workforce planning. We will improve training and ongoing learning and development opportunities for staff. That means creating more opportunities for joint continuous development and joint roles across health and social care, increasing the number of clinical practice placements in adult social care for health undergraduates and exploring the introduction of an integrated skills passport to allow health and care staff to transfer their skills and knowledge between the NHS, public health and social care.

The White Paper represents a further step in our journey of reform, building on the foundation laid in the Health and Care Bill, looking ahead to a future of health and care in this country with people at its very heart. It paints a vivid picture of a health and care system with more personalised care and greater transparency and choice, where early intervention prevents the most serious diseases, using the power of integration to give people the right care, in the right place, at the right time.

I thank the Minister for advance sight of his statement, which I got about 30 minutes ago, but I confess that I read most of it some 30 years ago when I was developing joint services. After waiting an eternity for the Department of Health and Social Care White Paper, the Government are spoiling us with their third paper of the year. All these papers are necessary to try to remedy the disastrous Lansley Act—the Health and Social Care Act 2012.

We acknowledge that reversing that Act and the integration of health and social care, however it is defined, is extremely difficult, but this integration will not be delivered by the White Paper and it is certainly not well defined. It is not clear how this fits with the Health and Care Bill, which is currently in the Lords. Even the experts involved in the Committee and elsewhere are repeatedly tripping over crucial issues such as the relationship between integrated care boards, integrated care partnerships and integrated care systems. How do they work with health and wellbeing boards? Where is the clinical leadership? Where is the accountability to local people? I banged on a lot about accountability in the Bill Committee so I am glad that somebody was at least listening and that we seem to have a bit of progress, but where are the voices of local people who are increasingly being asked to pay more for less?

Like a house made of crepe paper, this gossamer-thin White Paper collapses with the faintest breeze of scrutiny. Let us be clear: it is not a plan, nor is it even a starting strategy. It is just a series of woolly claims about how things could be better, unsupported by any evidence or analysis of the resources and organisational and funding flow changes that will obviously be necessary. It could have been written at any time over the past 30 years. It contains little that is new and nothing to illustrate new thinking or new attitudes. It relies on the bogus assumption that because something may work for a while on a small scale, it will obviously work everywhere. It is not any kind of plan for integrated care that people will recognise; these are just aspirations about integrated systems.

There is little to explain how a joined-up system would be managed, how it would be accountable to the public, patients and service-users, how the funding will be allocated and shared or how performance would be assessed and weaknesses addressed. Nothing in the White Paper addresses the key issue of balancing what is locally determined against national standards and national entitlements.

Crucially, there is nothing to address the key barrier to integration—that social care and the NHS are in different empires with no level playing field. One is means-tested and one is not. One has national criteria for entitlement and one does not. The way in which they are governed and funded is totally different and they are kept going by two separate workforces with no aligned terms and conditions.

I welcome the announcement of a skills passport and we will certainly look at the detail of that. However, unless there is pooled funding on a major scale—out-of-hospital funding—there will be no system drivers to really improve integration. This White Paper is again about simply encouraging, but we have had 30 years of that.

The reality is that the White Paper is remarkable for what it does not do. It does not seem to help children and young people. It does not address the challenge of how to care for and support working-age adults with a disability. It does not really value or assist the informal workforce or carers.

Our NHS and care system is under enormous pressure after years of austerity funding made incalculably worse by the impact of the covid pandemic, but the challenges that it faces are manifest, from a legacy of a “hospital first” approach to a decades-long failure to share care records. That runs alongside chronic underfunding and devaluing of public health, huge gaps in the workforce and wholly inadequate social care provision, with more than 500,000 people waiting for assessment and hundreds of thousands more denied access to care of any kind because the barrier for access is far too high.

This is a will-o’-the-wisp White Paper: one minute it is there before us only to vanish at a glance. The truth is that there does not seem to be anything of note that cannot already be done. Fundamentally, what is the point of it? As things stand, the number of patients waiting for care will continue to rise for the next two years, and there is no plan—not even the ambition—to get waiting times and waiting lists down to the record lows seen under the last Labour Government.

Worse still, these proposals will see patients paying more in tax but waiting longer for care. The Government are blaming covid, but will the Minister tell us when the target for NHS patients in England to be treated within 18 weeks was last met? If he cannot remember, it was in fact in 2016, four years before the pandemic. It is clear from the announcement yesterday and here today—just as it is from the decade of Tory mismanagement that left the NHS ill-equipped to cope with covid—that the longer we give the Conservatives in office, the longer patients will wait. Their time really is up.

Today is not a serious endeavour; it is a greatest hits of soundbites and buzzwords, randomly assembled to make a decent press release and get an outing on the evening bulletins. It is a desperate desire to own the news cycle and calm Tory Back Benchers’ nerves. It really is disappointing and it is simply not good enough.

It is a pleasure to see the shadow Minister in her place—she will know that I genuinely mean that, because she and I spent many happy days upstairs in Committee debating exactly these issues. This White Paper sets out clearly the next steps and builds on the strong foundations of integration that that legislation put forward, with the integrated care boards, integrated care providers and integrated care systems, which our deliberations in Committee and in this House demonstrated were clear, understandable and effective in providing locally based governance; bringing together at an ICB level NHS services within a locality, and within an ICP broader ranges of services, including housing providers and others. This has been bringing together the national health service we have with the localised delivery we all seek.

That is one of the key points of the White Paper: the next steps in how to deliver place-based solutions and allow the system to continue to evolve organically through that permissive approach that characterises the legislation we are putting through Parliament, rather than the prescriptive approach that the Labour party at times appears to prefer. The White Paper contains new thinking on new ways forward, drawing on not just the lessons of the pandemic but much longer-standing arrangements within localities, recognising best practice for integration between health and social care, and reflecting that organic development that occurs within a place as local leaders, local communities and those using the services work together to deliver services that work best for them.

The hon. Lady touched on how some of this might work in practice and talked about funding and budgets. We have made it clear—I used to use this when I was a local councillor—that section 75 of the National Health Service Act 2006, on the ability to pool budgets, has been effective, but it is time to go further and explore whether that remains the most effective vehicle by which that sharing of budgets can be undertaken, so it is right that we look at this.

The hon. Lady touched more broadly on social care and the NHS. I have to say to her that we announced our White Paper for social care last September. She mentioned the plethora of White Papers. We rightly recognise the different parts of the health and social care system and have clear plans for each of them. Those different White Papers together form a coherent whole, putting forward reform proposals that will make a difference for patients and others alike. I have to say to the Opposition that, much as they may gently chide us on this, in 13 years in government they had two Green Papers, one royal commission and one spending review priority, but still no reforms to improve social care provision in this country. This Government have seized the nettle and brought forward proposals that will genuinely move us forward.

Finally, on the hon. Lady’s points about yesterday’s announcement on NHS waiting lists, this Government have been transparent with the British people about the challenge ahead of us and about our plan to meet that challenge. Our approach, which combines ambition with realism, has been welcomed by stakeholders across the health and social care space. Ours is the party of the NHS. We are the party that has put the resources into that NHS, with £33.9 billion put into law at the start of 2020, and then record funding through the health and care levy, which the Labour party voted against.

As one in the long line of former Health Secretaries with scars on their back—to quote Sir Tony, if we are allowed to—from when they tried to integrate the health and care systems, I warmly welcome this White Paper. I think it is more than aspirations. But there are three central elements of the plumbing that we have to get right, and I want to ask the Minister, who I know is very committed to this, for his response.

First, previous attempts to have pooled budgets for vulnerable people have been bedevilled by the fact that the NHS has not wanted to pool its budgets with an underfunded social care system. The grant to local government is still not generous, to say the least. The Select Committee on Health and Social Care recommended an increase of £7 billion a year by the end of the Parliament, but it is actually going up by £2 billion a year. What will we do to overcome the resistance in the NHS to merging budgets with a social care system that is feeling very stretched?

Secondly, it is a very big step forward that everyone will have a single electronic health and care record by 2024, but my simple question is whether the public will be able to access the data. Patients are the best guarantors and defenders of their own health, so they should be able to access everything that professionals can see about them.

My third question is about having a single professional responsible for someone’s care. What is the role of GPs in that? For most members of the public, the central person responsible for their care is their GP. Is it not time to go back to the days when everyone had their own family doctor, instead of a different doctor every time they call the surgery? They might not see the same person every time, but there should be someone at the GP surgery who is responsible for their overall care, whether that is in the health system or the social care system.

My right hon. Friend speaks with typical wisdom and common sense on these issues. I will briefly address each of his three points in turn.

On pooled and shared budgets, I have to say that I think section 75 of the National Health Service Act 2006 has worked well. When I was cabinet member for health and adult social care at my council—I had more hair then, and it was not grey—I also sat on a primary care trust board as a non-executive member. I had a senior director of that PCT on my management team; we forged a common purpose, recognising that there would be some areas in which NHS moneys were greater than those put in by the local authority and vice versa, but the shared goal was achievable only when we worked together. I think that there is genuinely something to build on, and the ICSs, ICBs and ICPs at the upper level will be the vehicle to move the process forward. When I was doing it, there was a degree of personal relationship moving it forward, rather than necessarily a systematised approach, but I genuinely think that there is a willingness and a recognition of the need for this.

On public access to electronic records, my right hon. Friend’s central point is absolutely right: it is important to recognise that such data is our data and individuals’ data. We must always be wary about doing something to someone, as opposed to in partnership with them. That principle will underpin our approach in this space.

Finally, my right hon. Friend referred to a single responsible professional—not a single point of contact, but someone who brings together an individual’s care. He is right to highlight the importance of general practitioners. May I put on record my gratitude to GPs not only for all their work over the past two years, and for all they do day in, day out, but for the wisdom and care that they bring to addressing their patients’ needs?

Since my right hon. Friend’s time as Secretary of State, there has been a continual drive to increase the number of doctors in our health service. Not all will become general practitioners, but we need to continue to make general practice accessible and to encourage people to choose it as an incredibly exciting and rewarding career. One of the key elements of making what he describes work is building up a body of general practitioners who are able to perform such tasks. I pay tribute to his work; we are continuing that work and building on his foundations. I am grateful for his questions and for his contributions.

I am grateful to the Minister for advance sight of his statement. I think it fair to say that England is late to the integration game; Scotland and Wales have been legislating and moving in that direction for 20 years. The Scottish Government are pushing forward plans for a national care service to ensure that social care is fit for the 21st century, and have developed the NHS Pharmacy First Scotland scheme to spread the burden of frontline care and make pharmacies the first port of call for patients when GP and hospital visits are not necessary.

What lessons have been learned from the devolved nations? Any new plan for the NHS will not change the reality of the challenges facing the NHS organisation across all four of our nations, including that of vacancies. While Scotland’s workforce has grown by 20% under the SNP, Brexit is still hampering our ability to recruit from EU nations. Will the Minister discuss loosening Brexit and immigration controls with his fellow Ministers to help alleviate that situation?

I saw the hon. Gentleman’s final point coming. To his original point, we are always happy to speak to the devolved Administrations and learn from their ideas, just as I am sure they occasionally look to England to see what they can learn—that is part of being a member of this Union. I speak regularly to the hon. Member for Central Ayrshire (Dr Whitford), including about such matters. To his final point, all I would say is that since 2010 we have seen around 30,000 more doctors and 38,000 more nurses in the English NHS—I have highlighted the role that my right hon. Friend the Member for South West Surrey (Jeremy Hunt) played in that—so I think we are doing a pretty good job of continuing to grow the workforce. There is much more to do, but we have a plan and we are delivering on it.

I welcome this ambitious and much-needed programme of reform. One of the greatest challenges is ensuring the accountability of NHS bodies to local people, and I wonder whether the Minister could say a bit more about how these plans will ensure that local NHS bodies are accountable to the local people they serve.

These plans build on what we are proposing in our legislation. At the heart of the Bill are integrated care systems, which bring together at ICB level and ICP level the local authorities that are elected to represent their areas, local people—Healthwatch will have a key voice in this space—and of course the local NHS.

The clinical commissioning group in Barnsley says that it is struggling with unprecedented capacity issues. With a record 6 million patients waiting for planned NHS treatment across the UK, can the Minister explain how we will tackle the crisis in waiting times through this White Paper?

The hon. Lady will have seen yesterday the announcement and publication of our plan to tackle waiting lists caused by the covid pandemic, the investment that underpins that, the approach to the workforce and how we will bring those waiting lists down. This White Paper builds on that; they are complementary and work together. This is about looking to the future to improve how our systems work together, but we set out a clear and comprehensive plan yesterday to do exactly what she speaks of.

I declare my interest as a doctor. I wonder what the practical consequences of this will be. Can I suggest to my hon. Friend, whom I admire greatly, that one of those practical consequences might be to end the awful business of people waiting for weeks and weeks in acute hospital beds for discharge to more appropriate settings in the community? It does them no good, it is massively expensive to the system, and it prevents them moving on to places that can better care for them and give them what they need while allowing the acute sector to do what it can do, which is to manage people who are acutely unwell. At the moment we have 10,000 people in the system waiting for discharge. That will not do, and I would be interested to know from my hon. Friend how these proposals will help.

I am grateful to my right hon. Friend in this respect. Discharge of people from hospital safely, either into a care home setting or back to their own home with support, is vital not only for their own health outcomes but for the flow of patients through our acute hospitals to enable A&Es and other parts of the system to function effectively. Through the national discharge taskforce and through the work we have done throughout the pandemic, we are bringing together acute hospitals and local authorities, and we have made huge strides together within localities in improving this and learning lessons. This White Paper sets out a way in which they can be embedded to ensure that they continue to deliver long-lasting benefits.

My constituent Lynn is a powerful and loving advocate for her husband Andy, but she is at her wits’ end because she has to repeat the same information time and time again to nurses, consultants, dementia specialists, carers and the Department for Work and Pensions. When will the White Paper make her life a little bit easier? Despite her frustrations, she knows that all those professionals are working incredibly hard, but there just are not enough of them. How can it be that the Minister has said in this statement that he wants integrated care systems to have a joint health and care workforce plan, but he is still refusing to put that commitment to a workforce strategy into the Health and Care Bill?

I am grateful to the hon. Lady for her comments and for highlighting the situation Lynn and Andy find themselves in. What we seek to do, through what I said about care records, is exactly what she and I think they would wish to see, which is to reduce the number of unnecessary or duplicative interactions with the system.

She touches on workforce. I set out in my remarks earlier that since 2010, under this Government, there have been over 30,000 more doctors and 38,000 more nurses. In just the past year, we have seen a huge increase in the number of nurses—I think 11,000—and an increase of about 5,000 doctors. We continue to grow the workforce and we are already working to do so. My right hon. Friend the Member for South West Surrey (Jeremy Hunt), who is no longer in his place, set a lot of that in motion. We have also commissioned from Health Education England and NHS England, now that we have announced their merger, the long-term 10-year workforce strategy, which I look forward to with interest.

Kettering General Hospital and Northampton General Hospital have between them 1,100 beds, 300 of which are occupied mainly by elderly patients who have completed their medical treatment and await discharge either into a care home or a domiciliary care setting. Meanwhile, adult social care is provided by the two unitary authorities, which contract with over 80 different domiciliary care providers. Would the Minister welcome ambitious proposals from Northamptonshire along the lines of those already being pursued by Northumbria Healthcare NHS Foundation Trust, whereby the NHS itself provides domiciliary care? Unless we get those 300 patients into an appropriate setting out of hospital, our hospitals will for ever be clogged up.

I am grateful to my hon. Friend, who quite rightly never misses an opportunity to pay tribute to his local hospital trust. As he knows, I am always happy—as is my hon. Friend the Minister for Care and Mental Health—to hear any ideas for innovation that may improve outcomes for patients and communities.

As we have heard, councils and health service bodies have been taking the opportunity to work together in the absence of Government action. In Gateshead, we have a joint commissioning director for health and care, which has worked out very well. So things have been happening without the White Paper. The key to addressing integration is the workforce. With thousands of NHS vacancies and thousands of social care vacancies, we really need to address that issue. We need a comprehensive, detailed plan on restructuring the social care workforce to ensure it is recognised as much as the NHS workforce.

I am grateful to the hon. Lady, although I am not entirely convinced on her point about the absence of Government action. Yes, co-operation has been happening organically from the ground up, but that has been encouraged and supported by Government action—including various pots of funding, for example relating to discharge during the pandemic—driving that activity and helping to foster that culture of co-operation. She highlights the importance of the workforce and the need for increasing numbers. That is a point I have already acknowledged. I have made clear that the Government have a plan and are already delivering increases in the workforce.

I welcome the White Paper, not least because we have had to put through a very painful tax increase and want the Government to get on with things, but also because the Minister faces considerable challenges, including demoralising intransigence between competing bureaucracies, a hugely complex task of integrating information systems, and the need to rip up and replace the truly horrendous workforce planning system for change of pay and other conditions, as other Members have said. All those things are going to bog the Minister down, so will he do two things? First, will he set up a special taskforce to look at quick wins to start to deliver improvements? Secondly, reinforcing what my right hon. Friend the Member for South West Surrey (Jeremy Hunt), the Chair of the Health and Social Care Committee said, will the Minister agree to put control of, and full information about, patient records in the hands of patients, so that they can use effective choice?

My hon. Friend is absolutely right. He is, I think, alluding to the fact that quite considerable inputs in the form of taxpayers’ money and resources go into the system. Members sometimes fall into the trap of talking about inputs as the ultimate result, whereas my hon. Friend quite rightly talks about outcomes for patients and ensuring that money is well spent and delivers reform and improved outcomes. That is exactly what this paper is determined to achieve.

On my hon. Friend’s final two points, I will certainly consider taskforces. We have used one on tackling delayed discharge, so I know their value. I also take his point about data, and underpinning that is something that underpins all our work: co-design and doing things with patients, not to them. We must recognise that it is their data and that they should have control of it.

The Minister talks about ICBs, but he knows full well that they are able, under his Bill, to delegate functions and budgets to private providers, which represents a clear Government privatisation agenda.

The Minister talks about transferring skills and knowledge across the NHS, public health and social care, but how will that work in practice? Will the NHS be running training courses for private sector care organisations? If so, why should the NHS hand over valuable intellectual property and spend time gifting it to big business? Will he explain what that will mean for NHS staff?

We have had these debates before. The hon. Lady knows that the pace of privatisation was fastest under the last Labour Government, when the increase in spend on the private sector was much steeper. We have always been clear in our belief in the founding principles of our NHS, which is free at the point of need, but we have also been clear, as have every other Government since the foundation of the NHS, that there continues to be a role for voluntary sector organisations and private sector providers in that context.

On the hon. Lady’s final point, it is important, as in this White Paper, that we bring out the opportunity to help increase knowledge and share skills across the NHS, local authorities and the voluntary sector.

Given this excellent statement, it would be remiss of me not to thank the Minister publicly for the decision to retain the Frimley integrated care system, which was absolutely the right thing to do.

Will the Minister outline his plans for lessons from the best-performing ICSs to be shared across all ICSs, so that we can keep costs down and improve efficiency right across the network?

My hon. Friend knows, by virtue of the outcome, the persuasive and compelling case made by him and other right hon. and hon. Members from both sides of the Chamber in respect of Frimley ICS and its boundaries. As so often in this place, my view is, “If you ain’t broke, don’t fix it,” and his ICS is doing a fantastic job and other ICSs can learn from its success. Mechanisms and organisations through which chairs of ICSs get together and share best practice already exist, but we will continue to examine whether that could be better systematised, so that best practice can be disseminated more widely.

We have heard already how budgets can be pulled, how place leaders can be appointed and, importantly, how shared outcomes can be set between health and care through our health and wellbeing boards with local authorities. Will the Minister assure me that accountability of the single accountable person will come through democratic structures, such as health and wellbeing boards or local authorities, to ensure that that if the public are unhappy, they can change things by voting them out?

The hon. Lady will know from the debates on the Health and Care Bill that we are moving forward with opportunities for local authorities to be engaged not just at partnership level, as some are already, but more directly with the NHS at the ICB level. Health and wellbeing boards will continue to be a hugely important part of that.

There is a lot of what, to me, seems to be rather mind-numbing jargon in the statement, but only one mention of nurses. Could the Minister tell me—ideally without the jargon—about the impact of the statement on the nursing profession?

As I mentioned in my earlier answers, this White Paper needs to be taken in conjunction with what we announced yesterday in respect of waiting list recovery, the September social care White Paper and, more broadly, our approach to growing our nursing profession, through increasing the skills and numbers in that profession. We are already well on target for 50,000 more nurses in the profession.

This White Paper looks at the specific aspect of the integration of social care and health and permissive ways for local areas to come up with their most effective place-based arrangements, many of which are already in development. It is, quite rightly, not specific about any individual profession, nor do we believe it should be, because it is for local places to develop their own local plans to reflect their local needs.