The Health and Care Act 2022 is a key piece of legislation of the UK parliament and primarily covers England. The Act renamed the NHS Commissioning Board to NHS England to ensure that the organisation could work closely with the Department of Health and Social Care to promote effective communication with the public (Department of Health and Social Care, 2019a). At the heart of the legislation is a desire to incorporate service users as central to the decision making of services offered by health and social care providers.
The Health and Care Act 2022 replaced the Health and Care Act 2012, which was considered to be poorly suited to modern health and social care services. The 2022 Act established integrative care systems (ICSs) as statutory bodies and brought NHS bodies, local authorities and care providers together. The commissioning of services, which had previously been overseen by clinical commissioning groups (CCGs), were merged into local ICSs; there are 42 ICSs across England. The purpose of an ICS is to ensure that people who use services have a stronger voice and are able to plan and design services that are more suitable to their needs.
The Care Quality Commission oversees and assesses the ICSs. The 2022 Act integrated co-production and co-design principles into health and social care provision. For community nurses, this meant greater engagement with a range of organisations that could deliver health and social care services. Such organisations include voluntary groups and charitable organisations. There are two parts to the ICS. Part one, the integrative care boards (ICBs) are statutorily responsible for NHS budgets and, alongside their partners, are required to establish a 5-year strategy to assist in meeting the health needs of the population. There are 42 ICBs across England. ICBs also have to ensure that the NHS in its area breaks even in its financial budget. Part two is referred to as an integrative care partnership (ICP). Each ICP has the responsibility to develop long-term strategies to improve services in health and social care, and must consider the health and wellbeing of people living in the area.
The 2022 Act placed a duty on NHS England to reduce inequalities in health and social care, and to establish the powers of NHS bodies to assess inequalities. In Wales, similar legislation, referred to as the Social Services and Well-being (Wales) Act 2014, placed a similar responsibility on health and social care providers.
History
The objective of the Health and Care Act 2022 is not new. Historically, many attempts have been made to increase the levels of patient involvement. While the creation of the NHS in 1948 was a turning point in the delivery of healthcare services, there was no mention of patient choice or patients being a part of planning the delivery of the service, except for the choice of GP practice (Department of Health and Social Care, 2019b).
However, after a series of cultural changes during the 1960s, ideas of individual freedom and choice began to disseminate into other areas of public life, with increased pressure for greater person involvement in decision making across a broad spectrum of public services (Michailakis and Schirmer, 2010; Allyn, 2016). During the 1970s, the idea that patients/service users should be included and consulted in healthcare planning began to emerge in a range of national and international policy documents.
From the early 2000s, it became a legal requirement, instead of an expectation, to consult with service user groups. However, no policy document or legislation has set out in clear terms the nature of the consultation. In the documents that mandated choices for patients, the choice was often restricted to set parameters. The Health and Care Act 2022 primarily seeks to address this by placing co-design and co-production principles into a statutory requirement. Part two of the act also reinforces the sharing of data under sections 95 and 96, to be able to compare data across the broad spectrum of health and social care. This section also empowerd the Secretary of State for Health under section 99 to receive information from providers of adult social care services, when requested.
Impact on community nurses
So, what does the Health and Care Act 2022 mean for community nurses? First, in relation to safeguarding, the Act established a new health services safety investigations body (HSSIB). The body can undertake investigations in relation to incidents which could have, or potentially have, implications for the safety of service users. The HSSIB has the power to:
However, the HSSIB can also allow service users, staff and other people to provide information in relation to patient safety for the purposes of further investigation, as well as act as a body that can disseminate information in relation to public safety to organisations to foster a culture of learning. There was also a duty placed on trusts and foundation trusts to ensure that that there is no use of modern slavery or human trafficking in any of the supply chains to the NHS (Modern Slavery and Human Trafficking Act, 2015).
Community nurses are also expected to work much more closely with doctors, hospitals and social care providers in order to deliver joined-up care. There is also an additional emphasis on prevention and care in community settings, highlighting the need for the community nurse to be more focused on public health strategies with patients. However, this is not something new; the concept of prevention rather than cure has been discussed for decades.
Most community nurses are facing higher workload pressures, including increased caseloads and staff shortages, which is also observed across the health and social care sectors. There is a risk of the Act becoming embedded within the rhetoric of working in closer partnerships, while the reality of minimal resources could result in key areas of the Act not being met. Although working in partnership is great from a policy perspective, with limited resources in community care, delayed discharges will continue to curtail secondary care provision.
There is also some concern that the Act is too ambitious (Toh and Haynes, 2022) and that while the legislation attempts to bring the NHS, local government and the voluntary sector together as more equal partners. How balanced this partnership will be is yet to be determined. There is a risk that the legislation is not extensive enough and working in equal partnership could be restricted to discussions within an ICP. There is no way to determine whether such discussions will have a real and substantial impact on ICBs in relation to how the resources are spent or managed. For the legislation to really work, it has to view how services operate and work through the lens of the service user.
Some of the controversial parts of the legislation have been dropped by the incoming Labour government. The social care cap of £86 000, which was initially introduced in 2014 and subsequently postponed to October 2025, would have limited the costs of care to the cap amount. However, on 29 July 2024, Chancellor Rachel Reeves abandoned the policy. While the removal of the cap brings social care back to the status quo, long-term issues in relation to the payment of social care remain, and there will be a call for the government to outline its vision for the personal funding of social care in the future. For instance, in Scotland, the Community Care and Health (Scotland) Act 2002 allows for free personal care for adults, irrespective of income or whether they reside at home or in care.
Community nurses will have a significant role to play when working with the Health and Care Act 2022—with more emphasis on integration of services both in the primary and secondary care sectors and fostering good relationships with the voluntary sector and patients, there is an ambition for enhanced seamless care. Nevertheless, increased involvement of primary care in health and social care has been part of government agenda for decades. It remains to be seen if this Act will see the necessary resources for those working in primary care to make a real and tangible difference.