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Wednesday 06 January 2021

MiP welcomes new plans to speed up devolution

By Mercedes Broadbent

MiP welcomes new government plans to speed up the devolution of health and care, and put England’s embryonic integrated care systems on a firm statutory footing.

ICS devolution stickies

Local Integrated Care Systems (ICSs) in England are to set to receive more powers and funding under a government blueprint designed to speed up the devolution of health and care services to local communities. 

The report, Integrating Care – The next steps to building strong and effective integrated care systems across England, published by NHS England and NHS Improvement (NHSE/I) at the end of 2020, sets out plans to devolve functions and resources from national and regional levels to local ICSs from April 2021, and to develop effective models for joined-up working between NHS and social care services. It also outlines proposals to put ICSs on a statutory footing from April 2022. 

Place-based working

The proposed changes will allow funding and resources to devolved so decisions about services can be made closer to the communities they serve. ICSs will be expected to work across systems and with collaborative partners to ensure that:

  • financial resources are distributed fairly, targeting the areas of greatest need and tackling inequalities
  • operational delivery involves accountability between partners
  • workforce planning, commissioning and development is carried out collectively to safeguard staff wellbeing
  • emergency planning and response is comprehensively joined up
  • digital data is used well and accurately to improve system working 

The report describes ‘place’ as the key building block for health and care integration, recognising that most people have a ‘place-based’ understanding of the services they use, and that place-based services are more likely to notice gaps in service provision than regional or nationally planned services. The report also recognises that health and care services, as anchor institutions in their local communities, play a significant role in social and economic development and environmental sustainability.

Providers of primary care, community health and mental health services, social care and support, community diagnostics and urgent and emergency care will be required to work together with delegated budgets to join up services, with delivery built around neighbourhood Primary Care Networks (PCNs).

With hospital, specialist mental health and ambulance services, provider collaboration will sometimes need to be organised at entire ICS-level, or potentially even more widely, the report says. 

MiP chief executive Jon Restell welcomed the move to support the emerging ICS model with statutory changes. “Our members support the collaborative systems approach to population health management and service improvement,” he said. “They want to give the model a proper legal underpinning and effective management arrangements. The proposals in this document have been discussed for several years with broad consensus in the NHS, and they would have been taken forward much sooner if it weren't for the focus on Brexit. 

Putting theory into practice

NHSE/I has outlined a series of practical changes to be implemented by April 2021 to drive the development of ICSs across England. These include:

  • Provider collaboration: all NHS provider trusts will be expected to be part of a collaborative system and play an active leadership role in joining up services across systems – both within and between places. Systems will develop a “one workforce strategy” and create employment models and accreditation systems that allow staff to be deployed across the system.
  • Place-based partnerships: systems should make sure each ‘place’ has appropriate resources, autonomy and decision-making capabilities to support and develop PCNs; simplify, modernise and join up healthcare; identify and help vulnerable people and families; and coordinate responses to prevent future health risks to different population groups.
  • Local government: integrated care will allow for more partnership working with councils, accelerating the identification of, and response to, health and care issues.
  • Clinical and professional leadership: ICSs should embed system-wide clinical and professional leadership through their partnership board and other governance arrangements, including PCN representation. 
  • Governance and accountability: ICSs should put in place firmer governance and decision-making arrangements for 2021/22, to reflect their growing roles and responsibilities. These arrangements should ensure all system partners are involved in developing proposals for service changes, and that local people and local councils are fully consulted and engaged. 
  • Financial framework: NHS England will re-organise NHS finances at ICS level to put allocative decisions in the hands of local leaders, and create a single funding pot which brings together the budgets of CCGs, PCNs and other parts of the system.
  • Data and digital: ICSs will be expected to build smart digital and data services, in order to transform and connect services and put citizens at the centre of their care.

MiP has warned against repeating “the costly distraction and fragmentation of the Lansley reforms” as the new arrangements are put into place. “Managers across the NHS are stretched very thin and need support to continue to deal with operational challenges, not threats of redundancy,” Restell said. “There are opportunities here to re-focus finance, information and planning capabilities on performance and improvement, rather than contracting between providers and commissioning.

"After the Lansley disaster, our members are rightly worried about what's going to happen. We welcome the announcement of a stable employment guarantee,” he added. National employment frameworks and principles, negotiated with unions, will be vital to make sure the NHS gets the change right.”

Legislative changes

While a great deal of policy work can be done within the existing legislative framework, legislation will be necessary to deliver all aspects of the plans. In September 2019, NHSE/I made a number of recommendations for an NHS bill, including:

  • reducing the focus on competition between NHS organisations by limiting the Competition and Markets Authority’s role and abolishing Monitor’s functions relating to enforcing competition
  • simplifying procurement rules by scrapping section 75 of the 2012 Act and removing the commissioning of NHS healthcare services from the jurisdiction of the 2015 Public Contracts Regulations
  • reintroducing the power to establish new NHS trusts to support the creation of integrated care providers
  • powers to set up joint decision-making committees comprising commissioners and NHS providers
  • enabling NHS bodies to commission services collaboratively – it is currently easier in legislative terms for NHS bodies to work with local authorities than with other NHS organisations
  • a new “triple aim” duty for all NHS organisations to achieve “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer”
  • a formal merger of NHS England and NHS Improvement

Two options are being considered for enshrining the ICS system in legislation: a statutory committee model with an Accountable Officer, which binds together current statutory organisations, or a statutory corporate body model which incorporates the statutory functions of CCGs into ICSs.

Both options have both positive and negative aspects. The statutory committee model retains the individual organisational autonomy envisaged when these system changes were first planned, but it’s unclear who would ‘own’ patient outcomes or finances. The statutory corporate model would deliver a clearer structure and, with most commissioning work devolved to ICS level, allow for more place-based working. However, this model requires much more significant changes, which could be difficult to deliver during a pandemic. 

"We welcome the fact that NHS England is talking to the NHS about what to do next,” says Restell. “MiP will study the various legislative options and consult our members. It's so important that members let us know their views as healthcare professionals, so we can represent them and protect their employment interests.”

  • If you would like to contribute to MiP's response to the report, send us your views to MiP by email as soon as possible.

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