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The success of integrated care systems depends largely on the ability of statutory organisations to work together, which isn’t something that comes naturally to many NHS trusts.

Foundation trusts, in particular, were encouraged for many years to pursue their own priorities and interests, until the government realised this was costing too much money.

Changing that mindset is going to be tricky, says Donna Hall, the Bolton FT chair who has been working on the ongoing national review of ICSs, led by Patricia Hewitt.

She told HSJ in an interview: “I don’t know why FTs are still there. We should be bold and tie things together in a more integrated way. Getting organisations that historically hate each other to work together is really difficult because they’re so territorial.

“Maybe we need a new structure, because it’ll be really hard to change the culture and behaviours of these organisations.”

However, she acknowledged the Hewitt review would not recommend major changes for FTs, as this would provoke too much opposition.

Professor Hall’s imminent retirement means she is free to speak her mind, and she also aimed fire at her own system leader in Greater Manchester, Mark Fisher, for his comments about giving ICSs more powers for performance management.

Deficits domino

When it comes to admitting financial problems in the NHS, there is no advantage to being the first mover.

The five ICSs that dug in their heels at the start of this financial year and said they could not deliver a balanced budget faced extra scrutiny and additional controls.

Now the number of systems officially forecasting a deficit has risen by another nine. Plans that were signed up to just months previously are now undeliverable.

Other ICSs are currently reassessing their financial plans, and could reach nearly half of all systems, which only formally came into existence in July.

This is even after one-off cash injections and liberal use of reserves.

One has to wonder how much effort went into drawing up plans that were never likely to be delivered, just to keep NHS England happy.

The outlook next year is worse, as the one-off flexibilities padding out the finances this year will have been exhausted. “The chasm opens up,” one finance director said. “Virtually everything is gone.”

Nevertheless, the whole process now restarts: NHSE has insisted that plans for the 2023-24 financial year, which begins in April, must again break even. 

Also on today

In West Country Chronicle, Nick Carding says that nowhere are two-year waiters causing bigger headaches than in the South West, specifically Devon, and in a comment piece, Roger Kline examines what boards can learn about discrimination from the employment tribunal case lost by NHSE last week.