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.

Since the 2004 creation of Monitor, the national NHS leadership (at that time based in the department) has had to put up with a separate provider system regulator being a thorn in its side. Substantial tensions between the two have been a constant, although the flavour has changed a lot.

Creating a single executive leader of NHS England and Improvement – coinciding with the two organisations requesting a full formal merger – more or less closes that gap.

Most will agree that since they are merging senior management, it makes a lot more sense to have a single executive leader rather than two, and people trying to unite systems locally will particularly welcome the convergence. (That doesn’t guarantee they like the choice of individuals, and NHSE and I staff, still going through a painful and drawn out reorganisation, will be angry this leap wasn’t taken at a much earlier opportunity).

The move puts Simon Stevens, whose backing for integration and system working is unambiguous, in direct control of the provider side for the first time.

Mr Dalton had been pretty clear in recent months he thought strong NHS provider organisations were the first priority, and emphasised financial performance above all – while, like his predecessors, struggling to actually deliver on that because of inadequate income.


His legacy is having negotiated an NHS payment regime which is better for trusts and foundation trusts, just in time to hand over the fruits of this to Mr Stevens (and to the incoming joint finance director Julian Kelly). Trusts will lose their main champion at the centre.

Mr Stevens’ incentives could in theory now flip – he gets more accountability along with the additional power, particularly for the burden of provider finance and performance. When the 2017 Conservative manifesto supported NHS legal change it did so under the headline “holding NHS leaders to account”, and cited concern the current divided roles were “preventing clear national or local accountability”. While the government is now in absolutely no state to do much about it, Mr Stevens might feel the target on his back got a bit larger, though he is likely to stay focused on his mission.

As NHS Improvement chief, Mr Dalton has strongly favoured the old friends of merger and consolidation as the way to tidy up the provider landscape and make some savings, in tune with trying to develop strong (and large) trusts and foundation trusts.

Now that Mr Stevens has taken over, could we see a warmer climate for a wider range of approaches, including for small providers; and more progress on models like integrated care trusts, hospital groups, large scale primary care, and lead specialist service providers, as well as integrated systems? For example, progress with the plan to create a new kind of integrated NHS provider in Dudley has been glacial, though NHSI was not the only hold-up.

But building new primary and community services will require implementation nous as well as policy and enthusiasm from the centre, and some local champions of integration had looked forward to the disciplines they hoped Mr Dalton would bring. He also provided some counterweight to an often dysfunctional approach from NHS England to local leaders. NHSI chair Baroness Dido Harding is now a big influence nationally, which might mean welcome emphasis on the workforce, leadership and cultural aspects of integration; as well as potentially a more active chair.

Matthew Swindells, also now set to leave, has been a consistent champion of system working and particularly of population health initiatives; and has overseen integrated care system development. He determinedly connected technology to this agenda. Whether Matt Hancock’s NHSX can fill that gap is a pressing question.

Much about what happens now hangs on the appointment of the NHSE/I chief operating officer, who will also for legal purposes be the NHSI accountable officer – perhaps a weighty accountability to accept on a legally vague basis.

Desired traits

Desired traits for the COO include being a people person – both for the NHS at large and for NHSE and I’s battered staff; delivery ability; and the frontline realism associated with experienced local chief execs; but combined with commitment to quite substantially improve on current patterns of services. As several HSJ readers have pointed out, the person also needs to be cut out to enjoy and thrive in SE1 and Whitehall, which many local chief executives aren’t. With an ongoing dearth of diversity in the most senior ALB roles, someone who is not a white male would also be best.

It seems inevitable the COO will be saddled with ownership of day-to-day delivery and be the clear lead for trust finances and performance, as Ian Dalton and Jim Mackey were. The decision already taken for the seven joint regional directors, who are set up to be the engine room of delivery for NHSE/I, to report to the new COO, while Mr Stevens retains a presidential distance, underlines this.

This separation might maintain a creative tension and recognises Mr Stevens’ focus will really be elsewhere, but it does risk missing the point of bringing NHSE and I together in the first place. In recent years, the divide has often divorced transformation and improvement priorities from the real incentives, targets and other levers of NHS finance, operations and management. In many places, these have trumped the softer power base sustainability and transformation partnerships were meant to establish in order to drive service change.

Assuming this remains the approach, the question will be how successfully Mr Stevens and the new COO – who unlike Jim and Ian will have Mr Stevens as her (almost formalised) boss – can square these circles together behind closed doors.