The Integrator: How the ICS bill stalled at the 11th hour

Matt Hancock’s resignation on Saturday came at the eleventh hour in terms of his planned publication of the expected health and social care bill. It appears to have halted a government meeting that coming Monday which may have seen the document published by yesterday (Wednesday), or next week — just in time to get through the all-important second reading by Parliament’s summer break.

Understandably, the new health and social care secretary needs to be across the general thrust — if not the detail — of any new bill he will have to champion.

So far, there has been no “white smoke” on whether he wants to proceed before summer.

Thus far, I’m told, his discussions on it have been “more analytical than instinctive” — he “is thinking the bill through step by step”.

Mr Javid’s decision is expected, and hoped for by those who want to see it go ahead, by the end of this week — and that the decision could go either way.

The NHS Confederation, which has a big stake in integrated care systems, has made it clear its dream would be pressing on at pace with a a slimmed back health bill: closer to the proposals NHS England put forward, with none of the “bonus prizes” (ie more power for the health secretary) which Mr Hancock added on top.

Sources say the health secretary is holding a lot of conversations with Number 10 about the next steps. And Number 10, according to reports, has been getting cold feet, particularly over those “bonus prizes”.

A bill with major caveats around how the health secretary’s new powers are used could go some way to easing concerns. One example is the change requested by NHS Providers to prevent NHS England and the Care Quality Commission from being unilaterally dissolved — there are other ways too, such as confining the powers to particular circumstances, excluding some issues, or requiring high bars for intervention, as well as transparency.

ICS boundaries

Another of Mr Hancock’s gifts was a decision to require ICSs to match local authority boundaries — threatening NHS-shaped success stories like Frimley Health and Suffolk and North East Essex.

With his departure, this issue too has spiralled out of control.

On Wednesday night, former prime minister Theresa May, whose Maidenhead constituents are among those served by Frimley, was among MPs in the Commons telling the government they did not want their local ICS to be upended.

The change of health secretary gives these systems a lot more hope for carrying on than they had last week (but, one vociferous champion assures us, it was not they who leaked the infamous footage of Mr Hancock’s embrace).

Health minister Edward Argar told the Commons his own “preference is generally for evolution, not revolution”. He said Mr Javid “will want to consider carefully the background to this issue, the options before him… [and he] extend[s] his clear commitment to meet… members (of the house) before he makes any decision and decides how to proceed in this matter”.

In another session earlier this week, Mr Javid said ”no final decisions have been made on ICSs” and he would consider MPs’ concerns.

All that is positive, maybe, for the threatened systems — but it all sounds very slow, whereas laying the foundations for next year needs to get under way now.

If the bill misses its second reading before summer, given the other questions and controversies likely to rumble around it, getting ICSs into statutory form by April 2022 would seem very difficult.

It is certainly causing a lot of stress in those who have been working to the summer deadline for some time — and has inspired lots of public and private warnings to the new health secretary to get a move on.

Whisper it quietly though, there are some well placed figures who believe that even if the second reading was to happen after the summer recess, the April 2022 deadline could still be hit. They admit, however, that this would be far from ideal, cause further confusion among developing ICSs and require the parliamentary process to go off without a hitch.

ICS leaders are already concerned about the pace of the April 2022 timetable. Any tighter, and they may begin to say publically it can’t be done.

A delay of a year to ‘go live’ — which is one likely option — may in fact be appreciated by some ICSs, giving them a bit more breathing space. For the more advanced, however, it would be a great frustration. There is a risk of the direction being lost altogether, with the most independent minded trusts turning away from collaboration; and space for politicians and policymakers — including the new NHS England chief — to change priorities.

Then again, in effect, much of the NHS is already working to ICSs. A lot of financial allocations are going, in theory, through ICSs, and staff are already moving into the new roles, or getting ready to.

In the words of Macbeth, Mr Javid may have found himself “stepped in so far that should [he] wade no more, returning were as tedious as go o’er”.