The Integrator: The only way is reconfiguration

One of the many hopes pinned on integrated care systems was they’d be able to effectively plan and drive through large-scale service change. 

Their predecessors were too small and underpowered and hampered by a competitive system which didn’t encourage planning, with noisy foundation trusts motivated to protect their turf.

Now things are different. A bit. But by and large ICSs have not barked when it comes to large-scale change programmes.

Some say ICSs aren’t transforming much at all. Paul Corrigan, always interesting and particularly so with Labour marching towards government, wrote on his blog recently: “When you suggest to ICBs that they might actually implement their own plans, senior staff look at you as if you are extremely naïve. These are plans, don’t confuse them with actions.”

ICSs do in fact have numerous examples of things they’re doing, from better coordination of winter operations, to myriad projects trying to bind the NHS better into wider public services and the community.

But what is striking is they’re nearly always on a “micro” scale.

There are a number of theories as to why. Paul Corrigan points to the stifling level of priorities and performance management from the centre. Or perhaps there just hasn’t been time between pandemics, strikes, winter plans, recovery plans, financial meltdowns, internal restructure… the list goes on.

There’s also the lack of capital funding; and perhaps ICS leaders don’t feel they have the support and air cover which is needed from the centre, especially in the face of chaotic national politics.

It may be that all-encompassing, big-bang change programmes, and particularly acute care reconfiguration, just aren’t what’s needed in the 2020s: Has the belief which was common 10 years ago in centralising and specialising services – or even dictating a consistent service model across a large patch – been disproved and disowned?

Certainly, one integrated care board which has made clear it thinks big service centralisation is needed, Lancashire and South Cumbria, has received robust pushback from researchers who argue the financial and care quality benefits are doubtful. And, of course, it’s rarely easy or popular.

But nonetheless, for folks managing with departments teetering on collapse due to staff shortages, huge locum costs, or really needing a big “cold site” to churn through electives – it may be the logical answer (not to mention some areas without proper stroke units, or with substandard neonatal units). 

For community services, a single strategy (as in Dorset, the last of these big strategies I remember, back in 2016), can be used to promise integration and expansion ”close to home” (not always delivered?), while standardising the offer, and often removing costly community hospital beds.

So with ICBs facing big funding gaps, little hope for a cash influx, and being goaded towards “unpalatable” options, thoughts are increasingly turning again to reconfiguration.

As one ICB CEO (and former trust chief) put it: “The money is a massive issue. Do we have the courage to tackle the stuff that has been too difficult? More networked services, greater provider collaboration (end of the FT era?), and provider groups to drive back-office efficiency and workforce flexibility.”

Sussex reset

In Sussex, the ICB this week published a paper which appears to set it on course to a new county-wide service strategy, as well as resetting the system’s ways of working and decision making.

The paper is from Adam Doyle who as well as the ICB’s CEO is NHS England’s lead for ICB matters. It speaks of “fundamental change”, “choices about where to invest and disinvest”, and shifting “where patients are seen and how teams are organised to respond”.

The proposal is to task two new provider collaboratives – one for community and one for acute care – with designing and implementing new service models (as well as saving money).

The community collaborative will “design a core NHS community model of care” to be standardised across 16 integrated community teams; while on the acute side, a new “model of care [will be] designed to ensure we have evidence-based acute pathways as we transfer services and appropriate funding to the new community model”.

The ICB will move its transformation staff to “the provider sector in their collaborative form” – but the ICB will still chair a new committee-in-common for the new work, through which it can presumably badger the system to stick to its ambitions (and a pacy timetable).

Major service change programmes tend to be the work of years, if not decades, and in Sussex the ICB has decided it’s time to get the ball rolling. Perhaps other systems will follow.