New health bill may create ‘bureaucratic nightmare’, ICS leader warns

Dame Gill Morgan, former NHS Confederation chief executive and NHS Providers chair, is chair of Gloucestershire ICS and was appointed last month as the first chair of the Confed’s new ICS network “advisorate”.

Speaking exclusively to HSJ, she said ICS leaders were “concerned… [about] the bureaucracy and complexity” of the the emerging new governance structures for statutory ICSs.

She said: “We will have an ICS with two boards [an NHS board and a ‘partnership board’]. We will have ICSs theoretically having accountability responsibilities for the system performance, you have the regional offices having accountability for the performance of individual trusts potentially, and then we’ll have subcommittees [of ICSs].

“When you look at that, particularly if you’re in a big ICS, that could be an absolute panoply of meetings and subcommittees, all of which are valuable in governance terms but in delivering the vision of partners… to deliver longer term health [solutions], it could be a bureaucratic nightmare”.

Most ICSs are developing local “place” arrangements — which may have delegated committees — while provider trusts have been told to join provider “collaboratives”.

Dame Gill’s comments are reminiscent of a warning from Marcel Levi, who stepped down in the spring as University College London Hospital Foundation Trust chief executive after more than four years to take up a senior role in his home country. He warned fixating on the bureaucracy of ICSs would cause agile health systems forged during the pandemic to come to a “grinding halt”.

Dame Gill said ICS leaders “want to be asked, how do you intend to deliver governance? How do you intend to [deal] with conflict of interest rather than having prescription about how that should be done.”

NHS England is drawing up guidance for ICSs. This is expected to cover a range of issues, including how they should constitute their boards and how the senior figures will be appointed. Its publication is expected imminently. NHSE is also drawing up guidance on provider collaboratives.

Dame Gill noted this is the first NHS reorganisation involving a “significant difference between the organisations” being created, with some ICSs covering very small populations and others very large.

With this in mind, she said the draft NHSE ICS guidance risked being “overprescribed”. She added: “[The guidance] misses the very big, it misses the very small, and it might be okay in the middle. There’s a big anxiety that it is overprescribed and doesn’t recognise these fundamental differences between systems.

“It’s very easy, particularly when the people writing the guidance have often not had experience at senior level in the NHS, to try and nail [partnership working] down because they have a fear that, if they don’t nail it down, it will come back and bite.”

She said ICS leaders want “clarity” about what principles, priorities and outcomes are expected and then to be given “the opportunity to find good local solutions”, adding: “Prescription takes away the opportunity for innovation.”

By way of example, she said having a board-level chief medical officer and chief nurse — two roles HSJ has previously reported will likely be part of the core ICS board — would not be appropriate for all ICSs.

Reconfiguration

Dame Gill also warned Matt Hancock’s proposed intervention powers over hospital reconfigurations could take the NHS “backwards” and discourage engagement in local consultations.

She said there was “great concern [among ICS leaders] about what the secretary of state[’s]…. powers [over hospital reconfigurations] will genuinely mean”.

She said the new powers outlined in the government’s health and social care white paper, which would allow the health secretary to intervene in and call off any planned hospital or other service reconfiguration, may “take [the NHS] backwards as… we’ve [already] learned in the majority of places to do this as well as we possibly can”.

Dame Gill continued: “I’ve been really impressed… to see the quality of [reconfiguration] consultations, the proper engagement with citizens, [and] the rigour that things like the Independent Reconfiguration Panel have brought to the process. We’re in a situation where we have worked through how to do this.

“I would hate to see us move… to a system where there is intermittent and unclear intervention powers because, actually, what that will do in the long run is encourage people not to engage in local consultation. Because if you feel at the end of the day, there is a chance that somebody from on high will come in and intervene, why would you be participating? You’d wait and escalate.”

She also said there is a “very legitimate question” about who will be responsible for safety outcomes if the health secretary intervenes in a reconfiguration based on safety and clinical evidence, as happened earlier this year with Chorley accident and emergency.

Boundary disputes

Dame Gill added possible ICS boundary changes, which HSJ understands are likely to affect systems such as Frimley and Essex, is an “absolutely massive” issue for those affected as “all of a sudden [well-established partnerships] are going to be calved up and changed”.

She said at “least one” ICS has asked for boundary changes to be delayed beyond 1 April 2022, when ICSs will become statutory if the legislation goes through parliament as expected.

Dame Gill noted there was lots of work still to do ahead of ICSs becoming statutory bodies, such as winding down clinical commissioning groups with “thoughtfulness and compassion and caring for the staff affected”, while providing “clarity” over service recovery plans.

She added: “This is a really important leadership role for regional offices to help us get to where we need to be on 1 April.”

The confed’s new ICS network advisorate is a 21-member group from across the country which oversees the network.

Asked about how ICSs should be developed at the NHS Confederation conference today, NHSE chief Sir Simon Stevens said the focus should be on changing services and working together, stating: “Don’t start with the governance… reverse engineer from some very practical changes. Everything else is a means to an end.”