First, it’s important to recognise what the new document is. This is no new NHS Five Year Forward View or NHS Long Term Plan. It contains no specific commitments on new services for patients, nor does it come with a big cheque signed by HM Treasury (beyond what was previously announced to fund the NHS Long Term Plan) and it implicitly assumes the wider context of a strategic shift toward better integrated care and a system (including the NHS and its many partners) focusing on improving population health and reducing inequalities.
In essence, this is primarily a 'wiring' document: setting out the way the NHS will work in an institutional and structural sense, including with its key partners in local government. Yet unlike other attempts at 'wiring' documents, it is also clear on the key role of local leadership, relationships and attempting to leave more to local determination. While it does also contain proposals for new legislation it’s important to keep this in perspective given that any legal changes are some way off (2022 at the earliest) but also that the wider system-working this document looks to underpin is critically dependent on new collaborative ways of working between leaders and teams across health and care. You can’t legislate for that.
Ambitions for the future system
Though building on progress that pre-dates the Covid-19 pandemic, the document also looks to ‘bake in’ the better system-working that many observed during the Covid-19 response and prefigures a new world based on:
- system-working at 'place', which will usually mean a local government footprint but does not have to if other meaningful communities exist and make sense at local level
- new provider collaboratives between NHS trusts and foundation trusts, working at integrated care system (ICS) level or across multiple ICSs alongside place-based collaboratives uniting providers of health and care services, across both NHS and potentially other types of providers
- the ICS itself, for which NHS England and NHS Improvement proposes new legislation that would establish them as statutory bodies.
This will mean a lot of change for commissioning bodies (and the staff who work within them). Even if there is no legislative change, NHS England and NHS Improvement wants all clinical commissioning groups (CCGs) to merge on to an ICS footprint, and under its preferred legislative option, CCGs come to an end and are folded into ICSs. Related changes occur to specialised commissioning, much of which also passes to ICSs. This is intended to be part of a move toward more strategic, outcomes-based commissioning (though that has been a goal for some time and does not rely on these changes).
If this is making you switch off because it all sounds a bit technical, here are the key takeaways.
The end of the internal market has been announced rather a lot in recent years. But this document emphatically drives a few more nails into the coffin. It promotes the proposals NHS England and NHS Improvement put forward in 2019 to end compulsory competitive tendering, and it would be hard to imagine a less ‘market’-like approach than expecting all NHS providers to come together and co-operate in the new provider collaboratives. If there is any hint of the ‘old world’ left it may be that a statutory ICS that absorbs CCGs might risk having the look and feel of a rather large commissioner. The representation of provider collaboratives (along with other providers like primary care) within the ICS might argue otherwise but it will be something to watch as more detail emerges.
The response to Covid-19 saw co-operation and integration leap forward in many areas. But this co-operation was often at place level, not at ICS level. So, it is welcome that the document clearly looks to build on, and cement, this better system-working across NHS providers, primary care, local government, social care and the voluntary sector. Commitments to devolving budgets to place level and the creation of provider collaboratives at place level also support this. However, it is not intended to put place on to the same legislative footing as ICSs probably for good reason given the enormous variation in local context and relationships across England. But it will need effort and persistence to help build system-working at place level, balancing the benefits of a more permissive approach against the risks of lack of clarity over what the relationship between an ICS and a place should look like. Likewise, ICSs will need to ensure they don’t get overly distracted by national demands at the expense of losing focus on their constituent parts, particularly at the level of place.
While it’s difficult to argue with the direction of travel set out in the earlier part of the document, the lack of detail underpinning the legislative options (which are consigned to five pages at the end) leaves multiple questions which, until they are answered, makes it hard to come to a view.
Placing ICSs on a statutory footing should provide greater transparency and accountability, which makes sense, not least given how much public money will be routed through them. But the devil will be in the detail. Exactly what powers will an ICS have over a foundation trust? How will tertiary and ambulance providers handle the fact that they span multiple ICSs and may need to sign up to multiple plans and provider collaboratives? Local government clearly is a key partner at place level, but how will the relationship be framed at ICS level, when, after all, these will be statutory NHS organisations? And what, if any, powers will a provider collaborative have over its members? It would be too much to expect this document to go into so much detail, but without it many questions remain. While the direction of travel toward integration and collaboration is clear, there are important questions over exactly where the balance gets drawn between system collaboration and organisational independence.
Lastly, it will be important to learn from previous reforms that have tended to exaggerate the benefits of structural changes and underestimate the costs and disruption they bring. While it’s good to see NHS England and NHS Improvement openly concerned about the implications of legislating to abolish CCGs, it’s not clear whether this could be achieved without falling into the trap of another distracting reorganisation. The document also notes that the Department of Health and Social Care may re-draw one other boundary, namely, the one that gives NHS England and NHS Improvement its independence from government. Again, we’ll need to see exactly what is proposed here, but suffice to say, few will want a world where politicians can intervene in clinical and operational issues, at least without some strong safeguards.
Thanks, Sir Richard and others. I rejoice to see the end of CCGs, as their fatal weakness was that Bevan's democratic deficit was not filled by delegating health to local councillors, like Morrison's social care, but to unelected GPs who didn't ask for the statutory responsibility, are not trained or capable of managing a budget that was about £75bnpa in 2013, and is now 3 times that at over £200bnpa, and were already overwhelmed, so have just been talking shops, I followed them closely in Brighton and Hove, and wrote up my finding in about 100 papers on section 9 of www.reginaldkapp.org.
I see the future as Primary Care Networks managing expanded social prescribing, by medication to meditation, with GPs socially prescribing psycho education coursesn (exercise classes, mindfulness, bereavement, etc) in 10 week tranches, which are free at the point of use, and the providers are paid on receipt of the used prescription form, as pharmacists are pad for drugs. This will employ millions of complementary and alternative medics, who are the greatest underutilised resource at present.