We also shared our thoughts on the broader themes in a letter to Ian Dodge, National Director of Strategy, NHS England and NHS Improvement.
Thank you for the opportunity to set out our thoughts on the legislative proposals in Integrating care: next steps to building strong and effective integrated care systems across England. We have provided thoughts on the four questions asked, but also wanted to set out some broader themes here.
Integrated care systems (ICSs) should be rooted in, and connected to, the concerns of places, communities and patients. This includes ensuring that the voices and priorities of residents, service users and patients are captured and meaningfully reflected in ICSs’ governance and decision-making. The system-working could, and should, provide clearer lines of accountability with greater transparency and mechanisms for appropriate scrutiny and challenge as well for managing potential conflicts through lay and non-executive involvement and local democratic oversight. Governance and decision-making should build up from, and serve, place-based arrangements where much of the heavy lifting of integration will occur.
ICSs should also be genuinely collaborative, recognising the critical roles that all partners (not just local NHS bodies) will need to play to harness the benefits of integration and bear down on inequalities. This is particularly the case in relation to local authorities, voluntary and community sector organisations and ICSs will need the full engagement of primary care. In many cases, ICSs are too large for them to be the natural home of much system-working (which instead will occur at place) but clearly, given the powers they will have (not least over money), it will be important to follow the example nurtured in many more advanced systems where ‘place’ is at the heart of the ICS and the ICS explicitly builds up from its constituent places.
We can see how the changes proposed in the non-legislative sections of Integrating care can help deliver this model of working. Yet when turning to the legislative proposals themselves, this is not so clear and is complex, not least given the longstanding tendency to exaggerate the impact legislation can have and to underestimate the disruption that comes with it. Before the 2019 proposals there was an extensive round of discussion and negotiation on the recommended package and clarifying detail on what was intended. We continue to support that set of proposals. However, the track record of legislation makes us cautious in coming to a view on this new set, particularly, given this much shorter period of engagement (occurring at the same time as the Covid-19 pandemic), and the limited detail in Integrating care provided on the two alternatives. We set out some of the key remaining uncertainties in our detailed submission. In short, while it is possible either statutory form for ICSs could improve transparency, governance and collaboration and help take forward the vision for integration (as a moderate part of the wider changes set out), it is also possible that either would create a new set of problems to replace the old and that the very clarity and specificity that comes with a statutory model of an NHS body may create the risk that it also becomes more NHS-centric.
There are also complexities that cannot simply be legislated away. Many are created by the real-world pattern of patient flows and patterns of care, not by particular institutional structures. Many providers span multiple ICSs and simply removing `individual organisations veto’ will still leave them navigating through the complications of being part of multiple ICS plans (and even more place-based plans). The scale needed by many ICSs will also make them unwieldy vehicles for deep primary care and local government engagement whatever legislative route is taken.
Critical to overcoming these risks and ensuring that any legislative change supports the integration agenda will be the recognition of, and investment in, cultural and behavioural change (including in NHS national bodies and regulators). While you cannot legislate a change in behaviour or ways of working, these changes could be set out alongside and as part of, the legislative proposals to help understanding of how this new system is intended to work and much could be drawn from the earlier sections of Integrating care to do this. This could also helpfully be the subject of further engagement, particularly once the Covid-19 crisis has passed.
Whatever the longer-term benefits of legislation, there is also the burden of the immediate disruption that re-arranging NHS bodies brings with it. We welcome the intention to minimise this disruption but an honest assessment of the costs, and ways to reduce them, should be made.
Finally, although not formally part of the engagement process, the document also refers to the need for parliament to define in legislation the mechanisms by which NHS England and NHS Improvement will be held to account by the Secretary of State and by parliament. We are conscious that this has already been subject to some public discussion and is likely to be a key area of debate when a Bill reaches parliament, so would like to take this opportunity to briefly touch on this.
Ministers already set the budget for the NHS and hold NHS England and NHS Improvement to account through the priorities set out in the Mandate, which is subject to parliamentary approval on an annual basis. In his review of the first five years of NHS England, The world’s biggest quango, Nicholas Timmins found that these arrangements have worked reasonably well and that, in many respects, the establishment of the NHS Commissioning Board (as it was then named) has been one of the successes of the 2012 Act. His finding that most former health secretaries agree that the NHS should be operationally independent and run at arms-length from ministers is also very striking.
The merger of NHS England and NHS Improvement will create a very different body than the one originally envisaged in the 2012 Act, so it is right to take this opportunity to clarify its relationship with ministers and parliament. Clearly, it would be premature to comment further until proposals have been published but it will be important that any change to this aspect of the legislation should continue to ensure the clinical and operational independence of NHS England and NHS Improvement.
The King’s Fund remains supportive of integration and stronger collaborative working and wishes it to succeed. The thoughts set out above and in the Annex are intended to help its success, not to hinder it and in that spirit, we look forward to working with you on these issues going forward.
Richard Murray, Chief Executive