The Integrator: Baby steps again on specialised services

Many systems are now expecting NHS England’s long promised delegation of specialised services to be delayed and diluted yet again, having been pencilled in for April next year.

The North East and Yorkshire is a region where NHSE has done more than others to delegate to its integrated care boards. Its systems are large and less bankrupt than elsewhere and so in theory more ready to take the leap. Yet they’re among those declaring a collective decision to delay beyond the (already delayed) timetable NHSE announced early this year. Sources in several other regions say the same.

So what will specialised commissioning look like in 2024-25? 

NHSE still indicates some ICBs will get delegation.

Perhaps this will focus on London – where the two systems south of the Thames have been piloting delegation-light; and which, uniquely, services nearly all of its own demand.

It is hard to move to delegation on a piecemeal basis, ie permitting a smattering of keen/able ICBs around the country, because most of the services must be commissioned in regional joint committees of ICBs (as they were pre-2013).

In some regions, while there won’t be full-fat delegation, NHSE has promised more substantial joint working. NHSE regional teams have assured these ICBs that – regardless of where the ultimate power lies – nothing about their services will be decided without the nod of the ICBs/joint committee.

Significantly, work which worries big specialised provider trusts – on unbundling their funding from annual contracts with NHSE into system allocations based on population need – appears to still be alive.

Yet in terms of the crucial power shift, the agenda remains, in the words of ICB leaders, “baby steps”, with “NHS England still in control”.

Specialised commissioning teams will largely remain inside NHSE at the regional level. That avoids more destabilisation and the pain of splitting them up, but it strictly limits ICBs’ control, and means where some specific teams could usefully be combined at individual ICB level in larger systems (for example, in young people’s mental health, or neonatal intensive care) this will not be possible.

It won’t be absolutely clear what’s happening in 2024-25 until after NHSE’s board finalises decisions next month.

Many providers, research and patient groups remain concerned and resolutely against delegation, while others fret about losing control of spending. Then again, the ongoing “will they, won’t they” uncertainty is far from ideal, and holding back again further weakens ICBs’ ability to make changes and manage their systems.

In limbo

Of the four ICBs whose CEOs have stood down so far, I don’t think any has yet announced a substantive replacement: Devon; Mid and South Essex; and Bucks, Oxfordshire and Berkshire West all have interims in place and no long-term replacement announced. 

Leicestershire – where CEO Andy Williams is retiring, after a long career in Midlands primary care organisations, including notable successes in the Black Country – this week announced an internal promotion of its deputy CEO/chief nurse, “for an extended interim period”.

There seemed to be some hesitation about making the decision public; it’s an unusual system where all its main provider trusts now share joint leaders across neighbouring Northants. 

The upshot is that four out of 42 ICBs are now under interim CEOs, which raises obvious questions and concerns, although there is not a single common cause and some systems have had problems attracting candidates. But BOB had particular circumstances and opted for a local trust CEO on secondment. And Devon is said to be close to getting sign-off for a substantive recruit, likely stuck with the notoriously slow health and social care secretary (the latest NHSE board appointments have been stuck with government for ages too).

Midlands sticks

If it wasn’t for a countervailing trend in the West Midlands, the number of interim CEOs would be much larger still.

When ICB CEOs were first picked, five out of six of the ICBs in the region failed to appoint substantively (Birmingham and Solihull; Black Country and West Birmingham; Coventry and Warwickshire; Shropshire and Telford and Wrekin; and Staffordshire and Stoke-on-Trent).

Interims were chosen instead, sourced from a range of clinical commissioning groups and other roles in the same region, but from different systems.

This strange outcome was a result of a clash of ICB chairs’ strong views about who they wanted (and didn’t want); the desire of some in NHSE to attract CEOs from acute trusts, rather than commissioning or primary care; and the failure of the former to apply for the roles.

On top of that, those arguing for mergers are never far away when you’re in the “middle tier”, and especially bedevil the Midlands and South West, which have the smallest ICSs by population, and – in the case of the Midlands – some large and growing provider “groups” to contend with.

In the West Midlands, however, nearly two years on, all five interims have quietly become substantive; most recently Staffordshire and Stoke-on-Trent, which re-advertised the role in September then made Peter Axon permanent in recent weeks.

But although the Midlands has belatedly got behind this current structure and leaders, the recent flurry of interim appointments is a reminder of lurking instability. There is persistent fretting from some influential figures about the variability of ICSs’ size, governance, and how they do their job.