As the NHS experiences a degree of operational pressure never seen before in its 72 year history, we're also looking to the future. NHS England and NHS Improvement's Integrating care engagement exercise on the future of system working closed on 8 January.
This juxtaposition raises the immediate question of the timing of the next stages of this work. The initial proposals that eventually led to the 2012 Health and Care Act show the danger of rushing too quickly to significant change. Those delivering health and care services need to help shape the detail of any proposals before they are finalised.
There are many unanswered questions and a lot of detailed work needed for these proposals to work successfully on the ground. Creating the right process and timing to complete that work will be key.
There is, rightly, widespread support for joining up health and care services more rapidly and consistently to improve outcomes.
There is, rightly, widespread support for joining up health and care services more rapidly and consistently to improve outcomes, reduce health inequalities and make best use of limited resource.
There's also strong support in the trust sector for the key principles. Bringing health and care providers, and wider public services, together at a place, as well as an integrated care service (ICS), level. Trusts, led by a unitary board, remaining as the key delivery vehicle for secondary care. Providers working together more effectively in collaboratives - horizontally across their ICS and vertically in their local place. Commissioning becoming more strategic on an ICS, rather than smaller, geographic footprint. No re-creation of ICSs as "old style, full power" Strategic Health Authorities.
But, beyond these principles, important questions emerge on the detail, with a variety of different views on the right answers. This diversity of view reflects the different experiences, population needs and current local approaches to system working across the country.
Having worked closely with trust leaders to seek their views, there are four questions they believe need more work, building on the strong foundation that the clear consensus on strategic direction of travel and principles provides.
What are ICSs for?
The proposals set out an expanded role for ICSs to drive strategic transformation to improve population health outcomes. But they also require ICSs, under the favoured second legislative option, to be a formal NHS commissioner, performance manager and funding channel. If ICSs are to deliver both objectives, we need to ensure they are compatible.
For trust leaders, the principal focus of an ICS is to provide better joined up care and improved outcomes for patients and service users. That will require a full contribution from local government and wider system partners including housing, education, criminal justice and the voluntary sector. But will those partners be able to make that contribution if the ICS effectively becomes an internal piece of NHS machinery?
And on governance, trust leaders believe ICSs should remain a sum of their parts, with primary accountability outwards to the local population and its constituent organisations, rather than upwards to NHS England and Improvement. But it is unclear how the voice of service users, patients and lay members will be heard.
How will accountabilities, financial flows and governance work on a potentially crowded pitch?
The 2012 Act gave us trusts, CCGs, Monitor and the Trust Development Authority. These proposals give us Primary Care Networks and neighbourhoods, trusts, places, provider collaboratives, ICSs, more powerful NHS England and Improvement regions and NHS England and Improvement as a national body. Depending on the degree of formality and prescription at each level, this risks becoming an over-crowded pitch.
There is huge risk, complexity and resource in delivering health and care services. We cannot afford duplication, overlap and confusion on accountabilities, financial flows and governance. We must not add unnecessary bureaucracy or extra tiers.
The commitment in the proposals to strong organisational governance is welcome. But trust boards need to know how their legal accountabilities will align with any formal ICS accountabilities and more formal provider collaborative and place based structures. Particularly if organisational veto is removed, as proposed, at the ICS level. Trusts also want clearer proposals on what functions and resource will be delegated from NHS England and Improvement regions.
Is this the right balance between control and empowerment, uniformity and local variation?
Governments and arm's length bodies inevitably tend to design top down with Ministers, accountable to Parliament, at the apex, reinforcing command and control and uniformity. Those delivering frontline services tend to start bottom up, with services and service users, reinforcing local empowerment and legitimate variation to reflect local need. The best structures successfully balance this tension.
Each ICS is significantly, and necessarily, different from the others. These differences span geographic size and characteristics; the history of joint working arrangements; and the scale, spread and number of providers. ICSs have evolved to respond to those local circumstances and it’s essential that any national framework avoids creating a ‘one size fits all’ blueprint. There’s a concern that some of the detailed proposals are insufficiently permissive and fail to take account of that necessary local variation.
How do we enable a full contribution from all who need to make it?
Many trust leaders, including those in mental health, community and ambulance settings, do not feel that the current proposals sufficiently acknowledge the breadth and depth of their contribution and the difficulties the current sustainability and transformation partnership/ICS structure gives them.
For example, implying that community trusts have less of a role at system level is as unhelpful as suggesting that that acute hospitals have less of a role at place level. Ambulance trusts need more recognition of their role and greater support to work across several ICSs. Trust leaders also feel that the proposals could better reflect the key partnership role of local government, social care and primary care colleagues.
There are some very good foundations here. But more input on the detail, from a wide cross-section of those leading service delivery, including those who are finding system working difficult, is needed for these important changes to succeed.
NHS Providers' full response to NHS England and Improvement's Integrating Care document can be found here.
This was first published in the HSJ.