Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.

Look into most parts of the English NHS right now and you will see plans for clinical commissioning group mergers. And not for a vague point in the future, but for next year.

There are formalities to go through, and we haven’t run the numbers yet, but it looks to me like 2020 could see the biggest single set of NHS mergers for more than a decade, and perhaps much longer. The year to beat is probably the fall in 2006 from about 300 primary care trusts to about 150.

Another time I will cover the detail and consequences of the mergers themselves. For now I have looked at some changes going on in tandem with them – partly a cause and partly a consequence – with NHS providers and others stepping into the role of local system leadership.

More providers are embracing this as a large part of their mission, and it is being accepted more widely as a marker of a successful trust or foundation trust and its leadership – at least in some areas and for some trusts. What’s also on offer for the trust is even greater influence on big decisions in their patch.

A few examples have cropped up in my conversations and in HSJ news in recent weeks.

Bradford

First Bradford – an area the Care Quality Commission more or less described as the best system it had found in its first round of reviews. For some time, the NHS there has worked quite cooperatively, within and with other parts of the public sector. They have done nationally-leading work on diabetes interventions, and had some plaudits for curbing emergency admissions – not sufficient to avoid, unfortunately, pretty bad accident and emergency performance over the past year.

A recent advert for a new chief executive for Bradford Teaching Hospitals FT – which, with a £400m turnover, does reach a bit beyond its immediate district – required the recruit to also become “Bradford system leader”.

An appointment is awaited; while the system leadership role for the neighbouring Airedale, Wharfedale and Craven is already held by Brendan Brown, chief of Airedale FT.  

Performance at Bradford Hospitals is pretty messy but the system seems to have held together despite this. The patch is part of the West Yorkshire and Harrogate Integrated Care System.

Nottingham and Nottinghamshire

A little further south, in Nottinghamshire and Nottingham, bosses have been appointed for three “integrated care providers” which together cover the patch – another ICS.

In mid Notts, Sherwood Forest Hospitals FT chief executive Richard Mitchell has held the role for a little while and embraced it, while also keeping the previously very troubled trust on the turnaround path, achieving a CQC “good” rating.

It has been doing a lot of work with primary care networks, but with little talk of GP takeover, and prominent in its strategy is to “move beyond the boundaries of our hospitals and… help our local population become healthier”.

Progress has been harder in the patch’s main urban area, with political concern at Nottingham City Council and a large hospital provider beset by severe performance problems. But ICP leads have just been appointed for two ICPs covering these patches.

Perhaps the biggest win is that the new lead for Nottingham is the city council chief executive, Ian Curryer – seeming to suggest the council is now up for leading integration work with the NHS. (Check this out too: the area’s Keep Our NHS Public last month praised the approach of the ICS, which has managed to agree a fudge – but a neat, transparent and honest fudge – on competition requirements).

The other ICP – for southern Notts – is led by Nottinghamshire Healthcare FT chief John Brewin.

Croydon

Descending all the way to south London, in Croydon, interviews have been held for “a single leader” for Croydon Health Services Trust and Croydon CCG. To evade the legislation – which I believe does rule out a single accountable officer spanning provider and commissioner – the individual will legally be the chief executive of the trust, while holding a locality director type role with the CCG, under a CCG accountable officer shared across south west London.

For commissioners it is highly relevant that these developments across England are often coming alongside moves to revise, carve up and consolidate commissioning functions.

Some tasks will move to a merged CCG across a larger patch. The six Nottingham and Notts CCGs are planning to merge; as are the six in south west London; and discussions have begun about a potential three-way merger between the CCGs covering Bradford, Airedale, Wharfedale and Craven, which already share a lot.

Commissioning functions which don’t move to the larger patch can follow the local “system leader”, to their provider trust or perhaps council.

The Bradford systems and mid Notts say they’ll now begin making planning and prioritisation decisions together, including funding flows. Payment by results is ditched and savings sought collectively, and system finance director roles are in the works.

Some patches have already probably gone further – Cumbria is worth a close look – and similar moves will be discussed soon in many others.

Critics will say – among other things – this all risks tweaking leadership, governance and management, and in a very informal way compared to normal NHS accounting officer standards. But those involved believe they reflect important shifts in priorities, relationships and ways of working, and are starting to bear fruit in service improvements.

Updated about 9am on 14 June to correct the system lead for Airedale, Wharfedale and Craven.

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