Insider tales and must-read analysis on how integration is reshaping policy, providers, primary care, and commissioning. This week by HSJ commissioning correspondent Sharon Brennan.

We are approximately three weeks away from the release of NHS England’s and NHS Improvement’s long-term plan and there is far from a clear consensus of how commissioning should evolve in the years ahead.

Sir Chris Ham, outgoing chief executive of King’s Fund, made a significant intervention this week, warning the regulators would be making a “huge mistake” if they created a “blueprint” for how and when sustainability and transformation partnerships should become integrated care systems.

He said it would set the “cause back a long way” as he is adamant from his work with successful ICSs that these systems must be based on relationships.

Despite this I have heard from system leaders that NHS England is asking at least some to plan to become an ICS from 1 April 2019. Some explicitly state this in their board papers, such as Hertfordshire and West Essex STP.

It is not clear how widespread that ask is.

This suggested April cohort would be in addition to the third wave of ICS, likely to be announced before Christmas and involving a further six systems. Although NHS England has not yet confirmed who these six are, Devon is one likely contender.

To add to the complexity, the best performing current ICS are also seeking “maximum autonomy” from the centre which likely means they will be judged as a system, not as individual organisations, for their finances, quality and regulation.

With this in mind, it’s feasible the centre is looking to create an ICS ‘ladder’ in which systems move up towards autonomy nirvana as they prove they can work better together at each step.

The fear here is that the prestige of being an ICS is diluted if, in effect, all STPs are just rebadged.

However there is still no consensus on how to best spread ICS across the country.

In communications to CCGs seen by HSJ, NHS Clinical Commissioners said it was still “seeking clarity” about whether the long-term plan will prescribe a set number of CCGs it would expect to exist within a set timeframe.

Doing so would be a highly prescriptive approach and it is interesting the CCG members’ body is worried enough to seek an answer to this.

I have also written in the past that STPs were split in terms of whether to ask for legislation to mandate a move to ICS. In his interview with HSJ, Sir Chris blamed this desire to fall back on an ICS manual as a result of “learned helplessness” but it could be seen by some as STPs being very realistic about what can be achieved in their area without top down commands.

There is also something to be said about not having to reinvent the wheel 44 times over if the outcome – all health economies become ICS – is pre-determined.

NHS CC has also made five, wide ranging asks to NHS England around legislation, finance and accountability to support the move to ICS.

These include:

  • Giving providers and commissioners the ability to form joint committees for specific functions such as integration and reducing health inequalities
  • Replacing the payment by results tariff with a mandate for commissioners and providers to reach agreement. This would be supported by increased fines to prevent using arbitration as a default and additional monies being conditional on reaching agreement
  • Legislation to ensure both providers and commissioners have a responsibility for improving health outcomes across their STP/ICS as well as within their own organisation

The prescriptive nature of these recommendations aligns with NHS CC’s view that the development of ICS cannot result in a two tier health system.

As for a mandated timeline for transformation, although Sir Chris is clear it will prevent ICS from succeeding, giving a deadline for conversion could be another way of ensuring parts of the country aren’t left behind. This could also prove essential if politicians are to get on board with the redesign.

Sir Chris may or may not be proved right about the damage a blueprint could cause. But if the NHS is focused on moving ahead at pace with ICS then including a set of rules in the long-term plan, which work as a blueprint in all but name, is tempting.