What NHS England isn’t telling you, and more indispensable insight for commissioners. This week by HSJ commissioning correspondent Sharon Brennan.

All stick and no carrot might be a familiar approach for failing organisations in the NHS, but it seemed an odd stance for NHS England and NHS Improvement to take towards the first wave of integrated care systems.

HSJ revealed last week how most (possibly all) of the 10 nominee ICSs are rejecting the options laid out in 2018-19 planning guidance for them to take on a system control total. They say the proposed terms carry too much risk with very little benefit in exchange.

The approaches offered by the national bodies tie all or most national sustainability funding for NHS organisations within the ICS patch to delivering the system financial target – in a context where most trusts are highly dependent on this money.

The upshot is there would be a much greater chance of receiving more sustainability funding if the regions stick to organisational totals rather than embrace the brave the new world. It’s all the more risky in ICSs, which – as in most other areas – believe their control total targets are unachievable however they are presented.

These developments are one sign of the difficulty of driving reforms amid austerity, since in normal times you’d expect the centre to bung money behind pilot areas seen as making progress.

One HSJ reader comment put it in blunt terms: “Who would agree to put their STF at risk in return for some unspecified and minor changes to system oversight, based on system arrangements that have no teeth and depend on consensus?”

On one hand, the rejection could be viewed as a failure of system working with the organisations not trusting each other to deliver nor willing to share their pain/gain.

On the other, they have instigated a type of collective ICS bargaining to try to renegotiate some nasty financial targets, wielding the additional threat of embarrassment for the centre if there are no approved ICSs to announce in coming weeks. System working does not follow a predictable course.

The regulators are now reviewing the terms they have offered, with some expectation of a favourable deal being struck. One source told HSJ NHS England was rather embarrassed when it was pointed out that ICSs were likely to be penalised rather than rewarded if they signed up under the system-wide deal.

A compromise would chime with overall ICS policy, which has been very flexible and inclusive.

But it could also be seen as another setback for NHS England on this policy, which it’s been pursuing for several years, and a clear sign of the limits on system working under current legislation.