Key messages

We welcome and support the move to integrated local health and care systems. We also acknowledge that the current NHS legislative and regulatory framework does not fully support this direction of travel. We recognise that a complete re-write of the current legislative framework has not, at this point, been judged either feasible or desirable. Therefore we need to consider whether a set of carefully drafted and targeted legislative changes can help speed up a consistent move to integrated care. However, a proposed set of changes needs to pass the following tests:

• It must have been fully scrutinised, including extensive consultation and collaboration with the NHS frontline, and work to avoid unintended consequences.
• It must, demonstrably, be better than the alternative options, that is, using the existing legislative framework to drive the required integration and/or waiting for the time when we can recast the NHS legislative framework in its entirety. It is important to note how much can be achieved within the existing legislative framework.
• Given this proposed approach seeks to amend the current legislative framework piecemeal, it must leave a clear and coherent legislative framework for NHS organisations to work within, with a strong commitment to good governance and clear lines of accountability.

We would broadly support a number of the proposals made by NHS England (NHSE) and NHS Improvement (NHSI), but it is important to also consider the cumulative impact of the proposals, which we believe would be significant. In particular, the proposals do not just seek to enable greater local health and care integration, they also seem likely to significantly shift the balance of power between local health and care delivery organisations and the national arm’s length bodies, strengthening national at the expense of local. We are concerned that this could negatively impact the local leadership, autonomy and innovation that are essential for the effective delivery of local health care services.

The current legislative framework is based on the principle that NHS provider unitary boards are accountable for everything that happens within their trust. Unitary boards combine an independent perspective with detailed knowledge of the organisation in setting strategy and culture, overseeing the work of the executive and being accountable to stakeholders. Whilst we support the need to enable greater system working, we are concerned that some of the proposals would cut across the centrality of unitary boards, potentially blurring accountability and increasing the chance of governance failure.

We welcome the engagement by NHSE/I on the proposals and the Committee's early scrutiny, and hope that the proposals will now go through the usual and proper channels for legislative development. It may be that, following reflection on responses to the current engagement document, a white paper is warranted before the proposals are developed as a draft bill and further scrutinised by a public bill committee.  While the changes are in some ways focused on amending technical details within the NHS’ structures and ways of working, they nevertheless would have a significant effect on the spirit and letter of existing legislation and the public’s understanding of NHS.