The Integrator: When ‘no strategy’ is best

My colleague Matt Discombe has reported that the government’s £200m discharge fund – announced in early January, just after the peak of flu-fuelled winter meltdown – has made little difference to the number of “no criteria to reside” patients in hospital, nor to the raw number of discharges taking place.

My view – and that of many others out in the system, as I wrote at the time – was that the intervention was “too late, short termist and… for the wrong thing… strictly earmarked for residential care beds. Most delayed patients need intermediate (health and social) care to rehabilitate, assess and support in own home – will take a multi-year staffed plan to get there.”

Intriguingly, sources who should know what’s going on got in touch at this point, and told me that in fact the fund could be used for domiciliary (rather than residential) care, and indeed a big chunk of it apparently has been used in this way.

Intriguing because integrated care system leaders, national NHS leaders, and policy folks were under the very strong impression it was tied to block booking residential care beds – since that’s what the guidance heavily implied at the time, and what Steve Barclay told the Commons.

It’s good news that the rules were, apparently, relaxed. Hopefully it will help reinforce the lesson – which is not lost on some in government – that what is really needed is a longer-term fix for getting staff into domiciliary and intermediate care. The sooner the first steps of that are taken, the more chance they have of reducing the winter pain.

Twenty-four hours to discharge

The weird thing about the NCTR number (also known as ‘medically fit for discharge’ or ‘delayed discharges’) is quite how impervious it is to change.

Since the sharp flu spike ended in early January, nearly every emergency care and flow indicator – from delayed ambulance handovers to four- and 12-hour waits – have drastically improved (albeit to levels worse than pre-covid winters). But not the NCTRs.

It’s no wonder NHS England’s new urgent care chief Sarah-Jane Marsh is looking to develop a different measure, of the time from when a patient is “ready for discharge” to when that is achieved.

The idea is it would give both local and national leaders a better measure to improve on, but it could also potentially enable a 24-hour discharge target, which has been mooted as part of a fledgling intermediate care/discharge strategy.

Providers for systems

In the latest “are we serious about this collaboration thing?” developments, HSJ colleagues and I had a good chat about the NHS’s toings-and-froings on this subject on the HSJ Health Check Podcast with new NHS Providers chief Sir Julian Hartley.

He was a big proponent of integration and system working at Leeds Hospitals, which he’s just left after 10 years, and he’ll be a big champion at NHSP. The fact the provider representative organisation has chosen someone who’s firmly behind the ICS project is surely positive, in itself, for the movement.

Sir Julian – a three times acute chief CEO, who also ran a primary care trust in the noughties – did not dismiss concerns about recent backtracking on the system agenda lately, with some looking to private providers/patient choice as levers, and payment by results being revived.

Asked about these changes, he argued: “If you look at what drives behaviours and the kind of incentives you create, it’s important to align those with that collaborative impulse and drive.”

On PbR, Sir Julian said his former trust has raised detailed concerns about current proposals (the trust’s esteemed finance director Simon Worthington is essentially the brains behind the finances of a ‘systems first’ NHS), and he hopes some of its shortcomings will be fixed.

Sir Julian is an enthusiast for provider collaboratives too, but – perhaps assuring to many of his members – less so for the creation of ever-larger megatrusts and groups under single leadership. He (like NHSE) are at pains to stress provider collaboratives are meant to complement ICSs, rather than to square up to them.

Despite that, plenty of interated care board leaders will not fancy their chances of reshaping local services if a local acute collaborative behemoth doesn’t like it.

FT futures

Assuming the NHS does press on down the path of system working, integration and consolidation, a likely next step would be to abolish the foundation trust model, which is suggested by FT chair and former council CEO Donna Hall in a new interview with my colleague Lawrence Dunhill.

Importantly, as Ms Hall acknowledges, there’s no chance of that happening right now – legislation is firmly off the agenda – but it could make the in-tray of the next government.

Integrated care strategies

Ms Hall also made some refreshing comments about the “integrated care strategies” which ICSs were told to publish by December 2022, and which she has been reviewing as part of her work for Patricia Hewitt’s ICS review.

The former council CEO gives a shoutout to West Yorkshire and Sussex’s for being decent, but says most others are “just motherhood and apple pie… very thin on substantive ideas to transform services and there’s very little mention of communities”.

NHSE’s Mark Cubbon told MPs last month that seven ICSs had not yet published draft strategies, and HSJ has identified which they are. We’ve also collated the strategies which have been published.

As one of our readers commented, it’s tempting to praise those seven for ignoring or resisting the temptation to publish a vacuous strategy for an arbitrary deadline.

Issuing threadbare plans doesn’t help build confidence, but ICSs and their leaders can hardly be blamed. Many have spent the past year a) going through governance and organisational hoops, and b) focusing as instructed on a series of NHS operational asks. The disruption from statutory reorganisations – even evolutionary ones – is always underestimated. New relationships with councils and others are still being built and rebuilt.

The question is, what can they do now?