• ICSs must move to “system oversight and scrutiny” role
  • But initially only small number of systems will be ready
  • Treasury deal on capital and training sought “sooner rather than later”

Integrated care systems cannot focus purely on transformation, and will gradually move to taking on performance management jobs from NHS England and Improvement, the regulators’ number two has said.

However, chief operating officer Amanda Pritchard indicated in an HSJ interview that, for most areas, “system oversight and scrutiny” would for now remain with NHSE/I regional teams, with only a very small number ready to take this on themselves.

Details are expected to be set out in a new oversight framework Ms Pritchard has been developing, due to be published in the coming weeks.

Planning guidance for 2020-21 said ICSs have “two core roles: system transformation and collective management of system performance”.

But Ms Pritchard said performance management was often misunderstood — and, for many ICSs, this would initially mean taking responsibility together for delivering and for improving care — rather than acting as local regulators.

Even the 14 areas which have been approved as an ICS are not all seen as ready to take on the full “oversight” role, it is thought.

Ms Pritchard said: “System oversight and scrutiny will hopefully increasingly be done through, with and by systems, when they’re at that stage of maturity, but at the moment for most of them we would expect that to be done in much more of a joint way between the region and the system.”

But she added: “It’s the right role for ICSs. If they are only ever going to be at the system transformation end of the spectrum, then the risk is always that we’ll have parallel lines between [the centre and] systems and organisations.”

‘Fast track’ year

Meanwhile, Ms Pritchard, who took up the role last summer, having previously been Guy’s and St Thomas’ Foundation Trust chief executive, said NHSE was aiming to accredit ICS to cover all England by April next year — but there would be a bar all areas needed to pass.

Last month’s NHS planning guidance — as well as linking about £1bn local funding to system performance — said: “Every part of the country is moving towards becoming an integrated care system by April 2021 so 2020-21 will be a critical year… as we start working through ICSs and [sustainability and transformation partnerships] on a ‘system by default’ basis.”

NHSE guidance has previously indicated systems need to be judged at a “maturing” level on its “matrix” to be named as an ICS; but the matrix is unclear on some key points, and NHSE’s previous director for system transformation said last year: “Essentially this isn’t going to be a pass [or] fail, hit the bar [or] don’t hit the bar.”

Ms Pritchard said there would be a formal “bar” to pass, rather than an assumption all STPs would simply have their title changed and, where necessary, be given a lower level of responsibility.

The asks in the planning guidance for 2020 include “a system partnership board”, a “leader with sufficient capacity, and a non-executive chair”, a range of ”capabilities”, financial decision making, “streamlining commissioning”, and capital and estates plans including technology.

Having these in place was particularly important because systems would be given functions like distributing money, she said. “We’ve tried to be quite clear about what must be in place [to be an ICS].

“And the rationale for that is, if we’re going to ask systems to take a greater role in things like distributing the money, supporting bids, and being part of capital decision making etc, then we have to have confidence that the capability, governance and leadership is there to deliver that.”

She said 2020-21 was a “fast track year” with an aim of getting the remaining 28 STPs to become ICSs. “There’s nothing like doing it for real as a way of building maturity at system level, as long as there is support in place to make sure people are able to do that,” she said. 

There are likely to be tranches of ICSs approved this spring, autumn and the following spring, and NHSE/I regional offices will work with STPs on that path.

ICS capital budgets await government settlement

The planning guidance for 2020-21 said NHSE/I will try to “increase the proportion” of revenue and capital funding which is allocated to systems rather than organisations.

The regulators’ chief financial officer Julian Kelly told HSJ capital allocations would be made to systems when government provides a “proper” capital settlement for the NHS.

The service has been pressing for the Treasury to set multiyear budgets for capital and education and training, which were not covered by the five-year NHS England revenue settlement in 2018. NHS leaders had hoped these would be confirmed last autumn, but the Budget was delayed due to the general election.

There will now be a government Budget next month — but it might delay making any further multiyear commitments on the NHS until a spending review later in the year.

On capital allocations, Mr Kelly told HSJ: “The aspiration would be we get a proper capital settlement from the rest of government and then we can allocate a pot of capital to an individual system…[and] having given it to you, you tell us what you are going to do, then you get on and do it.”

He said the centre would be keen for local systems to get on with upgrading estates quickly once they know their budget.

Mr Kelly said NHSE/I would prefer to get multiyear settlements next month, but that waiting until the spending review was workable.

He said the NHS people plan — now due in March or April — depended on some certainty from government over funding, but that waiting for the spending review was not expected to further delay its publication. 

He said: “We would always prefer to know sooner rather than later, and for capital the most important thing is being clear what’s the money for this coming year.

“Clearly also whatever we put in the people plan we’ve got to have enough confidence that the funding will be there so the NHS can follow it through.”

ICSs must move beyond ‘transformation’, says Pritchard