What should the NHS long-term plan say about STPs and ICSs?

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The NHS five year forward view created a permissive policy context that has enabled clinicians and others to innovate on a scale unusual in the NHS. Various care models have emerged across England, including:

  • development of local integrated community teams and hubs that are meaningful in each area

  • establishment of primary care networks enabling practices to collaborate while maintaining their identity, where they wish to

  • local hospitals working closely with primary care, mental health and community services in integrated provider partnerships, making use of different contractual arrangements

  • collaborations between two or more hospitals, through mergers or the development of group models, to deliver efficiency improvements.

Local-authority involvement is increasingly important both in enabling care to be integrated and to add momentum to moves to improve population health. Areas like Wigan illustrate what can be achieved where there is a sustained commitment to improving population health based on long-term partnerships between local government and the NHS. The involvement of the third sector in Wigan means that resources from many sources can be used to find more effective ways of meeting the needs of populations and communities.

Sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) are intended to be vehicles for helping to share and spread the adoption of new care models. Our research has reported variations in the progress being made by STPs and ICSs and has described the many challenges they face in working within the current statutory framework. In a long read published today, Nicholas Timmins sets out changes that may be needed to align the law with the work of STPs and ICSs, while noting the difficulties of securing support in parliament for these changes.

What now needs to be done to support STPs and ICSs to continue the journey of transformation? An important first step would be to align the work of the regulators behind the national policy commitment to partnership working in place. The local system reviews of the Care Quality Commission are a welcome move in this direction, as are plans to merge the roles of NHS England and NHS Improvement at the regional level. The combined regional offices need to develop a unified oversight and assurance regime to avoid sending conflicting messages to providers and commissioners. This should be enabled by a major programme of organisational development for regional offices aimed at developing new behaviours consistent with the ambitions of ICSs. 

Second, much of the additional NHS funding that the Prime Minister has promised must be earmarked for transformation, recognising that transformation holds the key to sustainability. As the National Audit Office recently pointed out in its report on new care models, the vanguards set up under the NHS five year forward view delivered less than expected because resources intended to support them were diverted into dealing with providers’ deficits. To be sure, these deficits must be tackled but using all the new money for the NHS to prop up outmoded models of care will be a huge missed opportunity. 

Third, national leaders should encourage further changes to the organisation of commissioning while avoiding the imposition of a national blueprint. There is particular need to work with the tension between reducing the number of clinical commissioning groups to align NHS commissioning with STPs and ICSs on the one hand, and a desire to secure greater engagement with local authorities on the other hand. The form of commissioning should reflect emerging understanding of the functions of commissioners in future at both the system level and in the places that make up the larger systems. Integrated commissioning between the NHS and local authorities is especially important in these places.

Fourth, national leaders should also be cautious about unsettling the work of successful STPs and ICSs by prescribing their size and working arrangements. Progress is fastest where relationships and partnerships have been built, particularly where there has been continuity in the leadership community. This work would be undermined if systems were required to merge around larger footprints. Collaboration between smaller systems is already enabling issues to be dealt with at scale and is preferable to redrawing lines on the map. 

Fifth, the NHS long-term plan needs to make clear that the fundamental purpose of STPs and ICSs is both to integrate care and to improve population health. The latter depends critically on partnership working going well beyond the NHS and involving local authorities and the third sector as full and equal partners. The devolved ICSs in Greater Manchester and Surrey Heartlands are showing what this means in practice and their experience needs to be studied and adapted to accelerate and spread the transformations evident in some areas.

Our work with STPs and ICSs suggests that national NHS bodies can be most helpful when they remove obstacles to progress and enable the development of local solutions appropriate to the needs of different areas. Continuing with this permissive approach and supporting local leaders to learn from each other should be at the heart of the new plan. And when the parliamentary arithmetic permits, the government should work with these leaders to propose changes to the law, as Simon Stevens and others have recommended

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Ernest Barlow-…

Position
Consultant Podiatric Surgeon,
Organisation
CLCH
Comment date
25 October 2018

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