Daily Insight: Who gets to mark the homework?

Complaints abound, out in the system, that the Health and Care Act 2022  hasn’t made decision making more straightforward (as the optimistically inclined had hoped) but instead made it more complicated.

Particularly common is the complaint from provider trusts that they’re having their homework marked twice: once by their local Integrated Care Board and again by NHS England.

For ICBs’ part, some are aggrieved they feel they’re doing pretty well as an organisation but, under the current oversight ratings system, are dragged down by their providers’ performance – and within that, predominantly on acute access targets A&E, rather than primary or community care, or public health.

Just look at Greater Manchester, they might add, where the ICB CEO has effectively been threatened with the sack over the performance of provider trusts in their area. It’s hardly a surprise that’s where their focus is.

These are some of the dilemmas NHSE has to try to square in its NHS oversight and assessment framework; ie the bureaucratic codification of how it rates and regulates trusts and ICBs.

In large part the tensions and contradictions in the oversight system can’t be escaped. NHSE isn’t going to leave trusts alone while finances and performance are as they are. Monitoring and accountability are also ingrained in ICBs’ job as commissioners and system managers. 

NHSE’s hope, however, is that the sharp edges can be smoothed. It wants to discourage excessive homework-marking by ICBs, and – although it doesn’t say it in black and white – that’s what the draft new Oversight and Assessment Framework, currently out for engagement, sets out to do. 

Ratings of ICBs will now be much more about their own capabilities as planners and commissioners and, when it comes to performance, on measures built around their ICBs’ core purpose of population health, rather than dominated by acute waiting times.

NHSE’s list of proposed ICB measures – as the latest effort to translate the ambiguous demands on today’s NHS into measurable form – is well worth a look.

An interesting question is how far – and how quickly – they could they push further down this road in future.

A new government would also likely want more simplicity in delivery, less conflict, and may well push for ICBs to focus more squarely on a mission of integration and prevention rather than managing secondary care. (Again, the Manchester example shows why achieving that under the current legislation and system isn’t easy).

The other side of the coin of all this for ICBs is the increasingly harsh accountability which will come with published ratings. NHSE’s choice of language – from “excelling” through to “insufficient progress” – is softer than the Care Quality Commission (whose own ICS ratings are, theoretically, also in the post). But it may also augur a change of gear in terms of pushing for improvement and change.

An on-off relationship

Talks to potentially merge two North West trusts are being reignited, despite opposition from one provider, HSJ sources reveal.

Warrington and Halton Hospitals and Bridgewater Community Healthcare have jointly announced intentions to “resurrect integration plans”.

Bridgewater is the North West’s smallest trust, having lost key contracts and been blocked from expanding into Liverpool over the last decade.

Initial merger talks stalled in 2019 amid pandemic concerns but Bridgewater’s change in strategy led to a reopening of discussions in late 2023.

Warrington Council’s push for integration reignited talks. Bridgewater initially denied merger plans but this week released a joint statement with WHH, saying: “We are working together to resurrect integration plans.”