Insider tales and must-read analysis on how integration is reshaping policy, providers, primary care, and commissioning. This week by deputy editor Dave West.
At HSJ’s first integrated care summit last week, a particular question lay behind a lot of the discussion: Will integration and system working get easier on the other side of the forthcoming long term NHS plan?
The message from the top is likely to be, ”now is the time to deliver on and universalise integration”.
The new NHS England chair Lord David Prior (who, incidentally, has agreed to resign the Conservative whip because of the new role) told MPs last month: “The Five Year Forward View… has proven to be pretty much on the button as far as I can see. It is now a question of implementing it, which is the critical thing over the next five or 10 years. Converting it into a detailed plan and implementation is critical.”
The long term plan contributors made their submissions to Simon Stevens and Ian Dalton a week ago, and a period of trade-offs and making the big calls now begins. With the plan now decoupled from an early Budget on 29 October, there’s scope for it to slip – in the tried and tested fashion – towards Christmas.
A local system planning bonanza will follow in the new year, with decreasing degrees of detail required on two year, five year and 10 year timeframes.
Presumably this will bear a striking resemblance to the vexed STP (sustainability and transformation partnership) process.
What it will do
Making some informed guesses, what will the long term plan do to try to promote integration and system working, and what won’t it do?
We can expect a tightening up of the definitions and requirements about integrated care models and structures. The aspects of planning, funding and managing that should be carried out at the level of “integrated care system” – typically covering quite a large area, potentially multiple top-tier councils – will be defined.
So will an ICS’s common characteristics. Must there be only be one NHS commissioning organisation covering the patch, for example, taking out some overheads? What access and/or preventative activities are the minimum to be a primary care network? From there, the centre will do more to press areas to declare which models they are heading for and when – a pipeline to integrated models. In your area, will out of hospital services be led by primary care networks, an existing trust, or by a new or evolving “integrated care foundation trust”?
When will they move onto an “integrated care provider contract”? Why are some care homes not covered by proper health services?
Renewed effort will go into patches where relationships and plans are bad, like the “success regime” of a few years ago, to try to get them to catch up with the ICS leading edge.
There will be a large expansion – already well trailed – of work to join up health and social care planning for individuals.
Finance and performance will more often be reported and planned across providers and commissioners, something that’s just now tentatively resumed at national level.
There may well be a published NHS wishlist of changes to the law. Getting any substantial legislation through Parliament remains unlikely for the foreseeable – but a wishlist will offer a clearer steer on the proposed direction. It will be emphasised that a foundation trust has responsibilities to its system and population, rather than only itself and its patients; will these be translated into potential legal changes?
There will be clear indications that, over the coming five or 10 years rather than two, there will be more radical changes to law, regulation, incentives, financial flows and the like.
What it won’t do
There won’t be large pots of revenue funding for transformation, nor will there be enough around for step-change investments in primary or community care. There won’t be new munificence for public health or social care. The bidding industry for smallish pots of capital, tech money, and a variety of national programmes, will go on.
The NHS will not become organisationally simple. Four years on from when Mr Stevens first told the service “the ‘N’ in the NHS” did not stand for “uniformity of frequently changing administrative arrangements”, it’s truer than ever.
More jobs, regulation functions and budgets will be shifted to ICS, and from national teams to regional teams, with the regulators’ local teams being phased out. More CCGs will combine forces, but numbers working in commissioning won’t fall rapidly.
Despite the proposed empowerment of regional directors, the NHS will not move back to the more predictable, hierarchical days of health authorities, or to military discipline and chains of command.
Local government will not be brought into the heart of NHS decision-making except in a few exceptional cases.
Providers and commissioners will still be separately chased up over organisational targets and financial performance, and on the receiving end of multiple programmes and interventions – even if they are theoretically coordinated by the same regional director.
The core of the current targets regime will stay, though the spotlight will more often be shone at system level, and on a slightly wider set of objectives for joined-up care, reform and inequalities.
Leadership locally will still be backed on an ad hoc basis, rather than based on job title. Local system management remains a mixed bag and a moveable feast - things like STPs and ICS will gain a little more, but not loads more, formal power.
An early test will be whether there’s clear and credible leadership in each system for the forthcoming planning round – whether it becomes a great deal clearer who calls the shots in each patch. Another will be whether the process feels a lot more natural, and more productive, than last time round.