Exclusive: Government considering single leader for local NHS and care services

Senior sources involved in the work confirmed to HSJ that the proposal could be included in the government’s planned integration white paper, which may be published before Christmas. 

HSJ’s sources said a key principle being explored at present was that each local area — referred to as “place” in current reform terminology — would share a person who was accountable for both NHS services (reporting to the NHS integrated care board, part of the integrated care system), and for overseeing social care (for which they would be responsible to their local council). 

Many ICSs contain several “places”, which are typically coterminous with the areas covered by upper-tier local authorities responsible for a city, county or borough. It is at ‘place’ level most integration of health and care services is expected to take place.

One well-placed Whitehall source said the aim was to ensure integration of health and social care services was pushed forward in all areas — rather than only in a smaller number of pioneers — and to ensure there is a clear understanding for each local area of accountability for outcomes and delivery.

Sources also stressed the plans were subject to ongoing discussions and there would be further engagement on how they are implemented.

Writing exclusively for HSJ today, NHS Confederation chief executive Matthew Taylor said the prime minister has a “preference for accountability to rest in the hands of a single named person”. He added ICSs could be asked to nominate these individuals, but this should be done without undermining the “widely supported framework enacted by the Health and Care Bill”.

A well-placed source told HSJ the planned changes would “absolutely not overhaul existing legal accountabilities” and would “build on the existing ICS direction”.

Some areas already have a single place leader with the kind of accountabilities under review. One commonly cited example is Calderdale in West Yorkshire, where Robin Tuddenham is both the council chief executive and clinical commissioning group chief. Others include Tameside, Bury, Rochdale and North East Lincolnshire. Some other areas have appointed ‘place leads’ in recent years, with some delegated authority across health and local government, such as local trust chief Matthew Kershaw in Croydon, but where they do not hold a formal role in a council.

Areas would be permitted to choose a trust chief executive as their place leader in an area under the plans being considered by government, HSJ understands, as a joint role with the council and ICB.

A single set of measures

Another part of the white paper plan under discussion would require each area (place) to agree a single set of measures it would be held accountable for. 

Whether these would all be set locally, or some nationally, is subject to ongoing discussion.

Proposals for encouraging or requiring areas to pool budgets across the NHS and local government in each place — and the extent of any national requirements — are also being debated. However, sources played down the prospect of government mandating substantial pooling of budgets.

Within most ICSs there are several “places”, so any requirement to delegate specific powers or NHS budgets to them would potentially narrow the ability of the ICS and their leaders to make changes.   

HSJ last week covered how a national requirement to pool budgets was being discussed ahead of the integration white paper, along with joint responsibilities and accountability. The proposals are causing concern among national NHS leaders because of the potential disruption to current plans, and what they see as a risk that budget pooling leads to councils effectively reducing care funding. 

Local NHS leaders have differing views on the issue, with some saying the pooling of budgets is essential, and arguing it requires a push from government, but others are concerned about the complexity, and whether a pooled funding pot could be safeguarded from the risk of councils reducing their input to social care.