The Integrator: The white paper fallout begins

The initial reaction to the government’s NHS reform white paper has been well-documented: a broad welcome of the move to greater integration and suspicion of an “unjustified” power grab by Matt Hancock.

But other concerns are bubbling up. I’ve been told that some of the details in the paper had either been worked up very quickly or dropped in without “any prior notice at all”, while others muddy the ability of the NHS to focus on local need.

Two boards brings confusion

The decision to create two parallel integrated care system boards – an “NHS ICS body” and a wider-remit “health and care partnership board” – was “rushed” according to one source close to the white paper review, and there are concerns among NHS organisations that as a result the two don’t sound “terribly integrated”.

Another high-level source pointed out that many ICS have brought in heavy-weight chairs and chief executives in recent times, who may now be looking at their remit and realising it only technically covers the board with the narrower remit (the NHS one). They said: “This could prove quite awkward especially if local authorities want to chair the HCP board.”

They added that there will have to be some form of fit and proper process for the new ICS chairs and chief execs now that these are going to be statutory bodies. Whether this would also have to be extended to heads of HCP boards is unclear, or indeed how and for what the head of each body should be held legally accountable.

Guidance is promised on how these boards should be set up and run, and it will have to be extremely deft if it is to stop the two boards clashing over where the power sits.

No notice over Hancock’s local hospital reconfiguration power grab

I have also heard from multiple sources that there was no consultation with NHS organisations about the paper’s plans for Mr Hancock and his successors to be able to call in local hospital reconfigurations at any point in the process (and abolish the current reconfiguration processes).

An expert following these changes on the local government side argued the creation of the HSP board may be enough in itself to deal with the “tricky” issue of local reconfigurations. They said the best way of “dealing with [reconfiguration] is to work with local government and the local community at an early stage. This won’t necessarily get everyone on board, but it will show transparency. I don’t see how bringing in the secretary of state into that process will help.”

The white paper states that the new ICS NHS bodies will have to have “regard” to the HSP board’s health plan for the area. This will mean that there’s more political scrutiny of any local reconfiguration plans, the local government source told me, and any national political interference “does not help with that shared objective”.

DHSC interference risks ’destabilising’ health economies

The white paper implies a clear shift from local to central control, a direction that gained speed during the coronavirus response and one DHSC is clearly not wishing to unwind. A senior NHS analyst said: “The accountability of almost every single proposal is about increasing the powers of the secretary of state and increasing power upwards. That could undermine local accountability and there is real worry this could result in a bypassing local democratic power.”

The same is also said about the move to create new trusts: in NHS England’s legislative proposals in November 2020 this power was to be given to the NHS itself. In the white paper it is now in Mr Hancock’s remit. As with the plan to be able to direct NHSE at will or dissolve/merge any arms’ length body, there was general bemusement about why the health secretary wants the ability to do this and what he would use it for. 

NHS Providers response to the white paper said the power to create new trusts ”opens up the potential for political involvement at a local service delivery level, and without sufficient safeguards could destabilise a local health and care economy”.

My recent story about possible ICS boundary changes also appears an issue seemingly led by Mr Hancock, against the wishes of some local organisations. One ICS source said before the white paper was published there had been “rumours” that he wanted to look again at ICS boundaries. The final paper indicates ICSs should be “coterminous with local authorities” — a line added subsequently to a late draft being leaked.

The same source said the main focus appears to be on the East of England as “that is where Matt’s [West Suffolk] constituency is and where other politicians are pushing for a tidy up”. They said any boundary change could have a knock-on effect on others in ways that aren’t yet considered.

Overall, one experienced analyst told me that “on principle alone there is likely to be strong push back on reconfiguration plans and wider powers for the secretary of state”. They said it was concerning that the powers were “open ended” and set out no caveats on how they would work in practice.

Conflicts of interest may unravel ICS financial processes

While the white paper set out a clear direction of travel for integration it does not yet provide clarity on how the finances will work nor how the commissioning framework will prevent conflicts of interest. One source said ICSs were already worried about conflicts of interest on shadow boards where the board might agree a huge contract with a provider that is represented on the same board.

One person told me “there is a discussion about wearing two hats, both physically and metaphorically” to overcome this, although it is thought this might not be enough to prevent justified legal scrutiny.

The issue about how FTs fit within ICSs is also not resolved. While trusts were mostly pleased that FTs’ autonomy was largely protected in the white paper, it leaves them liable for both the performance of their own organisation, and that of the ICS overall.

If this is not resolved in the final legislation, it could result in a conflict of interest in which some board leaders feel unable to legally commit to one or other of their statutory duties. The provider source said: “The stakes are very high and in the worst-case scenario the confusion over which duty trumps the other will become intolerable.”

A similar issue arises in taking on specialised commissioning, at ICS level, which I am told is likely to be done at a much slower pace than some would hope for. Trusts are still unclear how the suggestion that neighbouring ICSs would work together to deliver a devolved spec com budget would be implemented. It is not clear how this would be governed (for example, would a pan-ICS board need to be set up?), nor how board members could protect themselves against criticism that the spec com budget is just being divvied up among members.