Reinventing FTs and creating IHOs: autonomy, accountability and flexibility
Characteristics of an IHO
There is a lot that is currently unclear about IHOs, including the unique contribution they make to delivering the 10YHP and their role within a provider landscape that also includes new FTs and new neighbourhood models. The 'O' in IHO implies that it is a new type of organisation, and if this is the case primary legislation would be required. However, the wording in the 10YHP[xvii] ("the very best FTs") strongly implies that an IHO will be an NHS FT and may instead be understood as a delivery mechanism; a commissioning option, bringing trusts and other types of providers together. It remains unclear whether an NHS trust might take on the functions of an IHO, or whether the very best 'new FTs' might also be an IHO.
In any case, ICBs, as strategic commissioners, would presumably need to determine whether an IHO or IHOs would be of benefit within the local system, and whether this was their preference of the available options.
The form of an IHO should be determined by its function. Without clarity as to whether the intention is for IHOs to be responsible for all the health services used by the whole population in a particular geography, or instead service a segment of that population (eg older people or those with mental health needs) it is hard to determine the most suitable delivery model. Whatever view is taken should be evidence-based.
As noted above, according to the plan, IHOs must be the best new FTs. As the policy develops, it may become more obvious which types of organisation, or indeed formal partnerships of organisations, could hold the whole health budget make improvements in line with the policy intent. But as with authorising new FTs it will be important to focus on capability. Performance alone might not be the best indicator of readiness to run and contract a wide range of services:
In terms of IHOs – again it cannot be a mark of quality/performance alone. It must be rather a judgement as to whether an organisation has the capabilities to play the local leadership role that is required of them.
As the policy is worked through, national leaders will also need to explain how any ICB commissioning functions and any other responsibilities are transferred from one organisation to another, the role of the ICB and regional team where IHOs are authorised or commissioned, and ensure duplication of functions is not an unintended consequence.
When considering implementation, policymakers will also need to express a view about the relationship between IHO status, good performance, and organisational capability. The knock-on impacts on other local trusts of an IHO being authorised must be worked through. This may include how to deal with circumstances in which two trusts both want to take on the IHO role in their local area, or whether the authorisation of one IHO in a place would close off IHO status as a potential route for development for neighbouring trusts. Policymakers should also consider that for non-IHO providers contracted by an IHO there may be implications for these sub-contractees' relationships with their ICB.
As with provider autonomy, policy should make clear whether awarding IHO status is primarily a reward for being a good organisation, or a means of delivering better care for a population. It will be necessary to explore whether there may be competition-law impediments to providers commissioning themselves, and this would need careful consideration should IHOs be introduced.
There are good questions about legality, and whether IHO is a reward for performance or genuinely about delivering better care...
...Also there are questions about partnership working and relationships between IHOs and non-IHOs that will need much more attention, as I can see it being both a real positive, but also a wedge between providers.
Timely clarity about the policy intent, authorisation criteria and evidence-base behind IHOs is required to avoid speculation and distraction.