King’s Fund chief: Regulators poised for 'huge mistake' on integration

Sir Chris Ham said its developers were deciding how “prescriptive the long-term plan will be about the timeline, size and shape of future of ICS”.

The work is being led by NHS England, but with NHS Improvement and input from the Department of Health and Social Care.

Sir Chris, who will retire at the end of the year, added: “Some people would much prefer there to be a neat and tidy organisational map that describes how England will be in three or four years’ time, but that would be a huge mistake.

“For there to be a national blueprint and for people to start drawing lines on a map in the way we have seen so many times in previous reorganisations would fly in the face of all the evidence we have so far from the experience of ICS. [They] are fundamentally dependent on relationships and not structures.”

HSJ is aware of concerns the centre could set a minimum size for ICS, as well as choosing given dates for areas to become an ICS, matching their sustainability and transformation partnership patches, requiring clinical commissioning groups to merge, and fixing other governance and management demands.

In an exclusive exit interview with HSJ, Sir Chris indicated that some smaller ICS were “coming under pressure from national bodies” as they did not meet an assumption that systems should cover at least 1 million people. Smaller ICS include Frimley Health and Dorset, both of which have populations around 700,000.

The King’s Fund chief, who has worked closely with ICS leaders, said some systems were “pushing back” against this ask as they “don’t agree” an ICS requires the larger population.

Sixteen of the 44 STPs have populations smaller than 1 million, including four “wave one” ICS.

Sir Chris said abandoning the “permissive” approach to integration taken since the Five Year Forward View in 2014 “would set the cause back a long way”. It had given leaders the “latitude” to make improvements, he said.

He added the best way to spread integration and system working was for leaders of successful ICS to be given time to support people in other parts of the country.

Sir Chris also said:

• The leading ICS should move completely to system control totals in 2019-20, removing organisation control totals. He said the national bodies do not have the “appetite” to do this due to concern “about losing control over the money”. Organisational control totals are a “bust” system, he said.
• The main role of NHS England and NHSI in regulating ICS should be to “do no harm” and that the “mixed messages” were “one of the major barriers” to progress.
• Government needed to take “very clear and coherent action” if health and social care secretary Matt Hancock’s prevention aspirations were to succeed. This should include “taxes on alcohol, regulation of the food industry [including] taxes on sugar and salt in food”, Sir Chris said.
• “Iconic” hospital waiting time targets were not “going away anytime soon”, he said, but he indicated there were “hard choices to be made” about whether they could be deprioritised in favour of population health outcomes and integration.

Richard Murray, currently the King’s Fund policy director, will take over as chief executive in the new year.