While the proposals have been largely welcomed across the health and care system as supporting better joined-up care for patients, there are a few issues that require further clarification.
Issue 1: Two ICS boards
The proposal is for each ICS area to have two ICS boards: an ICS NHS board responsible for the day to day running of the ICS and an ICS Health and Care Partnership board responsible for promoting partnership arrangements, and developing a plan to address the health, social care and public health needs of their system. The Partnership Board would include local authorities and other groups, such as Health and Wellbeing Boards, voluntary and independent sector partners. This dual structure of an ICS board recognises that there are two forms of integration which will be underpinned by the legislation: the integration within the NHS to remove some of the barriers to collaboration, and the integration between the NHS and others, principally local authorities, to deliver improved outcomes to health and wellbeing.
The nature of integrating multiple stakeholders from the NHS to local authorities, social care provider and provider collaboratives adds to its complexity – not forgetting issues of governance and accountability. Thoughtful handling will be required.
The White Paper recognises that these issues will need to be worked out:
“…we recognise that ICSs will have to develop effective and legitimate decision-making processes, and we are giving ICS NHS bodies and ICS Health and Care Partnership the flexibility to develop processes and structures which work most effectively for them.”
Issue 2: A focus on ‘place’
Services will be designed and delivered at ‘place’ with it being one of the three protaganists of the new white paper. ‘Places’ will be coterminous with local authority boundaries and where we will see joint decision-making at play between local authorities, the NHS, primary care and providers of health and care services and social care.
The concept of place while simple in language can present issues for organisations that span multiple geographies for example. Some ICS boundaries may need to be redrawn to mirror local authority geographies and with that change, we are likely to see the disruptive effect of this change; in the terms of workforce restructuring and redundancies to new functions and roles in some ICS areas.
Issue 3: Duty to collaborate
NHS and local authorities will be given a new duty to collaborate “…across the health and care system and a triple aim duty on health bodies, including ICSs, as recommended by NHS England. This will require health bodies, including ICSs, to ensure they pursue simultaneously the three aims of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.” So with the unequivocal message for providers to work together in provider collaboratives we are likely to see significant areas of change.
This new policy will provide the Secretary of state for Health and Social Care with the ability to issue guidance as to what delivery of this duty means in practice recognising that collaboration may look very different across different kinds of services.
Issue 4: Joint committees
The development of joint committees is a hugely welcome addition in the White Paper, removing unnecessary barriers to joined-up decision making. Joint committees represent the potential to simplify governance arrangements and will allow boards to delegate responsibilities to other parties not directors of an NHS organisation. The creation of joint committee arrangements for ICSs is a big deal – it will enhance delegation to ‘place level and to provider collaboratives.
On this issue, the White Paper provides:
“We are therefore proposing to create provisions relating to the formation and governance of these joint committees and the decisions that could be appropriately delegated to them; and separately, allowing NHS providers to form their own joint committees. Both types of joint committees could include representation from other bodies such as primary care networks, GP practices, community health providers, local authorities or the voluntary sector.”
Issue 5: Clinical Commissioning Groups at an end
ICSs will take on the commissioning functions of the CCGs alongside some of NHS England’s functions within its boundaries, including new strategic commissioning functions. We will see allocative functions of CCGs move into the ICS NHS board alongside its strategic planning function.
Issue 6: Command and control
The new powers proposed for the Secretary of State do significantly enhance the ability for intervention and direction. But do these new powers seem so justifiable? Nigel Edwards of the Nuffield Trust thinks not, explaining that it is not clear what problem they are supposed to solve.
There are a number of sound proposals in this White Paper but it is important that these provisions receive careful scrutiny. But as ever, the devil will be in the detail.
We understand that the Bill is set to brought forward in early summer.