Ahead of the publication of the NHS long-term plan, the government has asked the NHS to put forward suggestions for legislative change to remove unnecessary barriers and support collaborative working in local health and care systems. In this blog, we explore what can be achieved within the legislative framework and what amendments to primary legislation would be necessary to retain a core benefit of the foundation trust model - the unitary board, and sufficient autonomy to drive innovation and improvement to meet local need.
One size does not fit all
As the shape of the NHS changes it is becoming evident that one size does not fit all and that while individual services will be available to all of the population, the form of the organisation(s) that deliver them will vary from one part of the country to another. The integrated care systems (ICSs) currently in the process of evolution are diverse and do not necessarily conform to a template.
As the shape of the NHS changes it is becoming evident that one size does not fit all and that while individual services will be available to all of the population, the form of the organisation(s) that deliver them will vary from one part of the country to another.Policy Advisor - Governance
At the same time, the collaboration between NHS Improvement and NHS England brings into focus what seems to me to be an uneasy fit between their various functions. However, it also raises opportunity to ask important questions, what is best done by the centre to support the delivery of services, what should be the role of regulation and where does good corporate governance and autonomy fit into a system of local systems?
So what needs to be done?
The fact that one size doesn’t fit all does not mean we will have a free for all or that each ICS will want to plough its own furrow. Membership bodies like NHS Providers and the national NHS bodies have a role to play in sharing information on what works and is replicable across the health and care sector. This could be followed at an appropriate time by principle based legislation that permits rather than proscribes.
The challenge to create sustainable systems is formidable. While more integrated care will undoubtedly have benefits for patients, non statutory partnerships are usually more difficult environments in which to make binding decisions, and to control, than single organisations. They often have differing cultures and rely on good relationships, relationships that are bound to change as personnel change. Non-statutory partnerships provide a short-term solution to collaborative working but are unlikely to be sustainable in the longer term. On the other hand, if systems are incorporated into a single large organisations, they can become unwieldy. The leadership lack the time and capacity to absorb the volume of detail necessary to control risk and the assurance role of the board becomes virtually impossible to carry out effectively.
While more integrated care will undoubtedly have benefits for patients, non statutory partnerships are usually more difficult environments in which to make binding decisions, and to control, than single organisations.Policy Advisor - Governance
A way forward that preserves the benefits of unitary board leadership and autonomy from the foundation trust model would be to use the existing trusts as one key building block for system working. This could mean four or five quite large vertically and horizontally integrated trusts, alliances of trusts and GP federations using a lead contractor model or a locally agreed variation. The degree to which social care and primary care services are integrated for patients could be tackled within existing legislation. The trusts together with their partners would form the system working together to commission and deliver healthcare to a population of around 3 million, which is manageable but not so large as to become unwieldy.
How could this be done?
- At local system level large integrated trusts could be formed by mergers/acquisitions. It would be simpler and neater to legislate to form the bodies, but that is an optional extra. A lead contractor model or variations such as the integrated care provider draft contract currently out for consultation, would be relatively easy to create, but might lack medium term cohesion.
- The ICS would need to be established as a body corporate led by a system board of directors. Initially this could be done by forming special health authorities under the 2012 Act, which would place time constraints on their existence, hopefully making them co-ordinators of the local rather than arms of the centre. Legislation would be needed at some stage to establish them as autonomous bodies corporate
- The mechanism for appointing the system board could be self contained, with the component trusts forming a nominations committee to appointing the executives and the non-executive directors being nominees from the boards of the component trusts.
- The ICS would need powers to commission services (in the first instance using delegations from clinical commissioning groups), powers to deliver services, general powers of competence.
- The accountability relationships between the system and the trusts would need to be based on subsidiarity. Private sector terminology is politically sensitive, but there is no public sector equivalent, for each system works in a group structure in the commercial sense of the term. The system acts as the owner and holding company that sets overall strategy and holds the subsidiaries to account and the trusts are subsidiaries with their own boards working to deliver their part of the overall system strategy. In organisational terms, the system and its subsidiaries would be a single overall body.
- Instead of a command and control role, a slimmed down NHS Improvement/NHS England could act as an institutional shareholder on behalf of the public taking a strategic oversight, acting as a conduit for political input - intervening in extremis but largely abstaining form interference in operational business. The regional functions of NHS Improvement and NHS England would be integrated into the system.
- It would be insufficient to have only the centre standing for and representing the interests of the public. Accountability needs a local element. This could be delivered by bringing together health and wellbeing boards across regions, widening membership to include a broader range of stakeholders and changing their role to patient/service user champion with limited/defined powers to hold trust boards and regions to account.
Almost everyone in the sector agrees that having more than one regulator of trusts and systems does not make much sense, but equally recognises that regulation in the NHS has been problematic and there has therefore been no impetus to bring together he regulatory function and staff associated with the Monitor part of NHS Improvement and Care Quality Commission. However, such a merger is desirable in the medium term and needs to be planned for now.
Much of the above can be pick and mix in the short term. In the longer term, we are likely to need legislation that is permissive, rather than prescriptive, and that acknowledges and welcomes diversity rather than seeks to unpick the current evolution within the NHS. We need central bodies that support the efforts of those providing services, rather than seek to manage and control. We also need to plan for a single regulator for health and social care. Finally, we should ensure that we don’t lose the opportunity to establish board leadership and unitary boards and the maximum of autonomy at system level.