Political and financial
The NHS has been centre stage in national politics in recent months as it celebrated its 70th birthday. In June, the Health Select Committee published a helpful report (Parliament, 2018) on its inquiry into Integrated care: Organisations, partnerships and systems. The report emphasised the core benefits of integrated care at the frontline, and reflected a number of our concerns including a need for greater clarity from government and the national bodies about the 'end state' for STPs, and an improved focus on communicating the benefits of integration to the public. You can view our written submission (NHS Providers, 2018) on our website.
In July, the prime minister’s long awaited announcement (Gov.UK, 2018) on funding confirmed a new ten-year plan for the service, to be followed by a new NHS Assembly of stakeholders, a five year delivery plan, and crucially, an average of 3.4% real terms funding growth for five years – or £20.5bn additional revenue for the sector. The additional funding provides welcome and much needed recognition from the government of the need for investment in frontline care. However our analysis (NHS Providers, 2018) shows that much of the investment, which is only applied to the mandate funding provided to NHS England and therefore excludes education, training and public health, will largely be absorbed in rectifying existing gaps in performance, leaving little to invest in transformation.
The additional funding provides welcome and much needed recognition from the government of the need for investment in frontline care.
A subsequent and important political change for the NHS has been to welcome Matt Hancock to the role of secretary of state following Jeremy Hunt’s promotion to foreign secretary. The secretary of state’s immediate priorities across health and social care – workforce, technology and prevention – do not suggest a lessening of the focus on collaborative working, or the STP/ICS mechanism specifically.
Legal and regulatory
Wholesale change?
With parliamentary time tied up with Brexit, there remains no window for a substantial revamp of the Health and Social Care Act (2012), although we understand the government is minded to make minor amendments to legislation where it can. Our view is that although the existing legislative framework does not prevent collaboration between NHS and care bodies, we are so far away from the spirit and letter of the 2012 Act, particularly with regard to issues of governance, that a substantial review of legislation will be required.
Accountable care organisations (ACOs)
Two judicial reviews against the draft ACO contract were launched by campaign groups, one on the basis that the draft contract diverges from the 2012 Act’s stipulations about the use of tariff and one highlighting a lack of public consultation and wider scrutiny of the ACO proposals. Both of the two judicial reviews brought against the draft ACO contract have now been heard and the court has found in favour of NHS England in both cases. NHS England is now consulting on the draft contract, under a rebrand as the integrated care partnership (ICP) draft contract. We remain supportive of ICPs as one potential vehicle to integrate services. However many trusts will seek to achieve the same outcomes for patients via other partnerships and contractual models including alliance contracting and other prime/lead provider contracts.
Our view is that although the existing legislative framework does not prevent collaboration between NHS and care bodies, we are so far away from the spirit and letter of the 2012 Act, particularly with regard to issues of governance, that a substantial review of legislation will be required.
We remain supportive of ICPs as one potential vehicle to integrate services in collaboration with local partners in their health and care system. Many trusts will seek to achieve the same outcomes for patients via other partnerships and contractual models including alliance contracting and prime/lead provider contracts.
Regulation and the resurgence of the regions
Meanwhile NHS Improvement and Care Quality Commission (CQC) continue to refine the existing regulatory frameworks to allow them to regulate organisational duties, and provide an assessment of system collaboration. CQC’s outgoing chief executive, Sir David Behan, used his final months in office to provide a clear steer on the need for new powers (HSJ, 2018) to enable CQC to assess 'system' working routinely alongside the quality of care delivered by individual providers. CQC has been using special powers to resource its pilot work on system regulation to date. The results from our annual regulation survey (NHS Providers, 2018) endorse Sir David’s views with 81% of respondents agreeing that NHS Improvement and NHS England need to develop new models of oversight to hold systems to account for collective performance.
NHS England and NHS Improvement recently announced (NHS Improvement, 2018) their intention to work much more collaboratively underpinned by a series of joint board appointments and joint posts as well as the development of seven new joint regional offices. This is a significant decision in terms of the national architecture as it essentially symbolises the blurring of the commissioner/provider split at a national level. Trusts certainly welcome the prospect of more joined up messaging from these two key national bodies. However we are also keen to understand how the new regional offices will relate to STPs, ICSs and local systems – as well as to organisations, notably trusts and CCGs – and to ensure that NHS Improvement’s provider sector focus continues to influence and inform national policy making.
This is a significant decision in terms of the national architecture as it essentially symbolises the blurring of the commissioner/provider split at a national level. Trusts certainly welcome the prospect of more joined up messaging from these two key national bodies.
A sustained focus on collaborative working
Throughout this period of flux, the theme of collaborative working has remained consistent as the core mechanism for change in national policy making. Following the introduction of ICSs in the planning guidance (Febuary 2018), in May 2018, NHS England confirmed four more ICSs had joined the national programme. We understand preparations are underway to develop support for future 'waves'.
In anticipation of a new engagement approach to develop the five and ten-year plans, Simon Stevens, chief executive, NHS England, has set out a number of priorities (cancer, cardiovascular disease, children’s services [plus prevention and inequality as they affect children], and health inequalities) (HSJ, 2018) all of which rely on a collaborative approach to succeed. He has also been clear that he sees 'integration' and the next five year plan as a continuation and ‘acceleration’ of the original five year forward view. We therefore expect a focus on collaborative working to remain central within the ten and five year plans, building on the following features of national policy to date:
- continued support for the evolution of ICSs, with the expectation ICSs take on a greater degree of autonomy in agreement between local partners and NHS England and NHS Improvement in return for adopting a system performance management role
- using STP/ICS footprints as an “aggregating footprint” sitting between individual institutions and the national level which will develop an important relationship with the seven new regional NHS England and NHS Improvement offices
- increasing clarity about the roles and functions of STPs and ICSs with regard to leadership, planning, performance and resource management and care delivery versus their sub footprints i.e. sub systems within a wider ICS/STP footprint at the level of ‘place’ (say 250-50,000 population) and neighbourhoods (up to 50,000 population) playing a prominent role in the design and delivery of integrated care models
- increasingly seeking to establish STPs and ICSs by using these partnerships as a vehicle for policy delivery such as capital prioritisation and creation of IT and estates plans. The secretary of state recently confirmed that almost £500m funding for technology will be devolved via STPs for example.
Although STPs provide one vehicle among many for local partners to drive more integrated ways of working, we would be disappointed if the five and ten year NHS plans failed to build on the investment trusts and their partners have made in system working via ICSs and STPs – or created yet another acronym! We will therefore be promoting the five and ten-year plans as a key opportunity to engage and work with trusts and their partners to build on progress to date, and to offer additional clarification around the role and functions of ICSs, STPs within the national system. We would also welcome greater acknowledgement of the role played by local or place based systems within an STP or ICS footprint, not least as this is the level of population where changes to the delivery of care, and vertical integration are most likely to take place.