The Integrator: Tussles for ICS influence are coming soon

Described as providing “some ‘guide rails’” for NHS organisations, the latest and much-anticipated NHS England guidance on integrated care systems leaves as many questions unanswered as those it deals with.

The document said the “purpose” of the document is to “give [ICS] the best chance of delivering on [their] four core purposes, in the urgent context of covid recovery”. Those purposes are improving health outcomes, tackling inequalities, better use of resources and “supporting broader social/economic development”.

Redundancies and conflicts of interest

The clearest bit of new information was on the makeup of the “ICS NHS body” board (as the more NHS-y of ICSs’ two boards is formally known). Rules in the document set out 10 mandatory roles as a minimum, which ICSs are expected (and likely) to add to. One of the (many) things left unclear is whether the same individual could wear more than one of these 10 hats — for example a local GP (one of the mandated roles) who is also the ICS’s medical director, or indeed its chief executive.

These members, the guidance says, will be “required to comply with the Nolan Principles of Public Life and meet the Fit and Proper Persons test”, but it dodges the details of how conflicts of interest will be managed, with local providers in a position to mark their own homework.

In a large ICS with multiple acute providers the job of sitting on the ICS NHS body may carry little appeal: The document says this person will not be a “delegate” for their sector — but they will have to be accountable for both their own organisation and the ICS overall. If the needs of both are at odds, how is that resolved?

The paper also fudges the pressing issue of the formal appointment of chief executives and chairs to the ICS NHS body as it refers only to a not-yet-published “agreed national recruitment and selection processes”. The involvement of the health and social care secretary in appointments is one hot topic hear: It looks likely they (or he, as it is at the time of writing) will have a veto over appointments of ICS NHS body chairs (at least the first one), but that their chief execs will be chosen by their local chair and NHS England.

As readers of our news story on all this commented yesterday, the huge issue of individuals’ place in the new world — and redundancy — rears its head here too. With systems having just over three months to formally appoint chief exec and chair, some criticised the process as one that will just roll over the current incumbents. Others said the NHS will have to pay out big redundancy packages if they are not carried over. The latter is something that was criticised under the last health reforms in 2012. But of course there are some ICS leaders who NHSE would rather take this opportunity to move on.

On the emerging picture of ICSs painted by the guidance, and accountability within them, NHS Providers deputy chief executive Saffron Cordery warned trusts were “increasingly concerned that the ICS model risks moving away from being a sum of its parts to a separate body managing those within it. There must be appropriate governance measures to ensure ICSs are accountable not only to NHSE/I and parliament, but also to the communities they serve and the organisations within their footprint”.

Two boards – who holds the power?

Also expect a bun fight over who gets to be the chair of each system’s “ICS partnership” — the wider membership board which will sit alongside the NHS ICS body. The document said “some systems will prefer the partnership and ICS NHS body to have separate chairs”. Both local government and the NHS may want a chair who is one of their own. But a failure to put local government at the heard of both boards might allow the ICS to miss the point altogether on the wider determinants of health.

The guidance says ICS partnerships will develop an “integrated care strategy” for their population covering health and social care, and addressing the wider determinants of health and wellbeing, such as education and housing.

The NHS ICS body is tasked with developing a “plan” to meet the health needs of its population which has “regard” to the partnership’s strategy. What “regard” looks like practice may in large part depend on personalities and relationships. 

NHS Confederation ICS network director and NHS Clinical Commissioners chief Lou Patten warned: “There is a real risk of the  partnership being perceived to have a far more diluted role than the NHS body.” For while these two boards are still both described as a statutory components of the ICS, ICS body will be an organisation, while the partnership will operate only as a “forum” committee.

Further guidance on partnerships is due from the Department of Health and Social Care — and the bill itself is due around the end of the month.

NHS England’s role

There are mixed messages about NHSE’ role in the new world.

The guidance says it is “reviewing [its] own operating model — including how our functions and activities will be carried out in future and how associated resources will be deployed”.

But, in primary legislation terms, the agency is set to retain its core commissioning functions, rather than — as some may have expected — see them fully transferred to ICSs. NHSE is “considering how it might shift some of its direct commissioning functions to ICS NHS bodies”, the paper says. It said it intends to delegate functions such as ophthalmology and dentistry to ICSs “as soon as they are ready to do so” after legislation is enacted. However the delegation of other functions such as health and justice, armed forces and some aspect of public health will be delayed until some point in the “future”.

As my colleague Dave West pointed out on twitter, the bill may well make delegation to ICSs easier than before, “but this [decision] feels a lot like the messy ‘delegation’ policy of the last seven years – not a reset of local/national split”.

It’s also notable that the issue of how the Care Quality Commission will assess and rate ICSs is clearly not yet resolved. The guidance says NHSE is still working with the CQC and Department of Health and Social Care “to agree the process… for reviewing and assessing systems” (the word “rating” is not used) and said the aim is that this “would complement the role of NHSE”.

Finally, NHSE says it will retain “similar” statutory responsibility for regulating providers – an assertion which may rile providers thinking the upshot is therefore that, in ICS, they now just have yet another master; while the ICSs more ambitious to lead from the front might wonder how that will be possible with NHSE looking over their shoulder. 

Overall the guidance, in its desire to give local systems the flexibility they asked for, leaves a lot to the imagination – expect more disputes and debates to come to the fore over the next month as people think through what this all means for their roles, organisations, professions and interests.