Speed over safety

The 2020-21 planning guidance made two things very clear — NHS England/NHS Improvement is intent on speeding up how local systems are working together, and achieving financial balance is now overtly central to its ambitions.

What was also hinted at in the guidance was confirmed in the appendices published a few days later — the role of leaders of sustainability and transformation partnerships/integrated care systems has been strengthened.

Appendix B said: “ICS/STP [are] to collate and submit” annual operational plans for most aspects of the system including finance, workforce, quality, specialised commissioning, plus the overarching narrative of what the system intends to achieve in the 12 months from April 2020. Commissioners and providers are to “contribute” in various ways to these submissions.

It is unsurprising therefore that the guidance said leaders must have “sufficient capacity” to take on this and other new roles. What is not known is how this translates to days per week; and how job shares, where STP/ICS leaders combine the role with leading a trust or clinical commissioning group, will be judged.

My recent analysis showed that only 10 of the 42 ICS/STP leaders currently do the job as their only role — most others share it with running CCGs (17) or a trust (six). It’s likely these numbers will start to shift from April 2020 as leaders recognise how much more is asked of them.

Secondly, major changes were made to the financial incentive regime that underpins STPs/ICSs and the organisations within them, which will themselves have a large impact on ICS leadership.

Half of the centrally held financial support available to NHS providers and commissioners will now be tied to the performance of their wider system. The new rules will apply to the “financial recovery fund”, which is available to organisations in deficit. The FRF is worth £1bn this year but will increase to at least £2bn in 2020-21 depending on the final outturn this year.

In 2019-20, only Dorset ICS decided to gamble all its provider sustainability fund money on reaching its system control total — other ICSs decided it was too risky, opting to pool much smaller proportions. NHSE/I clearly felt moving hard incentives to a system level can’t wait for people to take the leap of their own accord. 

The new guidance said leaders will also be taking a role, along with NHSE/I regional teams, in deciding whether organisations that missed their individual control totals should be given any of the financial recovery fund the system as a whole might have won through meeting its system control total.

This is added to the role leaders will likely have to play in ensuring ICS financial, quality and workforce plans are feasible — leaders will likely have to oversee heavy negotiation and compromises between organisations to ensure ICS plans add up.

However, it is going to take strong leaders to weather the fallout from some of the financial decisions and dilemmas they are now being handed — and, as I said in my last Integrator, for many systems these are only just beginning to emerge.

It remains to be seen how many STP/ICS leaders are experienced and embedded enough to stand up to trust chief execs who may well be relying on the bail-out money to meet their own organisational statutory requirements. This situation is further heightened when we remember that STP/ICS leaders don’t have any statutory authority — only that which can be agreed by their systems and formalised in memoranda of understanding.

To some extent, NHSE/I have acted to prevent some of the ill feeling that will be the result of sharing financial risk across STPs/ICSs which aren’t ready or willing to do so. In the recent planning guidance, NHS England said cumulative deficits recorded against CCGs — which cannot feasibly be repaid — will be subject to large write offs, typically of around 50 per cent. A similar bail-out for trusts is also under discussion but has not yet been agreed. This will remove some of the pain for organisations with a healthy balance sheet, which fear losing money to indebted neighbours.

Amanda Pritchard, NHSE/I chief operating officer, made it clear in an interview with HSJ that 2020-21 is seen as a “fast track year” in which the “aim” is to convert all STPs to an ICS — yet without lowering the “bar” of what is expected of an ICS in terms of governance, capacity, and planning. 

Whether the bar is applied as rigorously to all areas — ability of leaders to collaborate perhaps, strength of leadership, or performance and delivery, for example — remains to be seen. 

I’ve speculated before that the April 2021 deadline could be moved or some STPs could become ICSs in name only. It seems NHSE is now intent on a third option — cajoling, encouraging and penalising systems to get them over the line.

Ms Pritchard stressed NHSE/I would put plenty of support in place — and even existing ICSs won’t take over some aspects of regulatory decision making for some time.

But what the centre risks with this option is losing the emphasis on those relationships we are so often told sit at the heart of a successful ICS. Increasing the speed of transformation may get systems where NHSE wants them to be but it does risk compromising and fracturing relationships, which could resonate well beyond April 2021.