The Integrator: Systems expecting instructions on exec roles

Integrated care systems are likely to be told to recruit to new executive roles, as well as new non-executives, amid rising concerns the timing for ICSs to become statutory organisations is becoming “very tight”.

The second reading of the health and social care bill in the Commons is likely to take place by the end of July this year, when Parliament heads into summer recess. It should then gain royal assent by March 2022.

There are fears, to be frank, that if the government cannot meet that July deadline, it will be almost impossible for ICSs to become legal entities by April 2022.

But even if this schedule is stuck to, multiple leaders have told me the tight timeline is their biggest concern, especially as there is still no guidance from NHS England on crucial issues such as board composition, conflicts of interest, HR frameworks and provider collaborative set-ups.

From what I’m hearing, much of this work is in train, but final decisions are yet to be made as NHSE tries to develop guidance that will work for most.

It is now highly likely a chief medical officer and a chief nursing officer will be part of the core ICS NHS body board, joining the already confirmed CEO, chair and CFO — although crucially none of the post-holders are yet formally confirmed, with changes expected in many systems.

The introduction of the CMO and CNO will likely be how ICSs are held to account over quality, especially as the Care Quality Commission is expected to rate these systems.

Other roles are under debate as well, with the board also likely to consist of primary care, an acute sector CEO, and local government representatives. What happens in the many systems where there is more than one acute per ICS is not yet clear, although some systems are raising concerns about the number of new roles being created.

Saying that, I know of at least one ICS that will have a mental health chief exec too — something that will please that sector and some campaigners, but will probably not be a national ask.

It also seems almost definite that each ICS will be expected to have independent non-executive members of its own, rather than being guided entirely by local representatives and stakeholders. One ICS leader said a majority non-exec voting board would almost certainly be needed if the NHS is to prevent conflicts of interest over contract awards (as organisations being awarded contracts may well have a seat on the NHS board).

They said NHSE is increasingly taking the view the Nolan principles should be adhered to when it comes to resolving this financial conflict, which makes the idea of a majority voting non-exec board more likely.

Crucially, to stop the boards from becoming unwieldy in size, the local provider representatives who do sit on it may not be given formal voting rights at all. That could be something providers struggle to accept, since ICSs are meant to be guided by their local system rather than have their own independent agenda (tricky, too, if the ICS exec lead comes from a local provider?)

What’s clear is all of this needs resolving soon, so ICSs can advertise, interview and recruit for these roles as soon as possible and the organisations can use the time from September onwards as efficiently as possible.

Delegation conundrum

Another issue beset by the tight timing is when best to pass on those NHS England powers which are due to move to ICSs — crucially, specialised services commissioning. This is expected to happen from April 2022. However, many systems are concerned they just won’t be ready to take on the work from this date, not least because they won’t have the skilled staff in place.

A new NHSE design framework is currently in draft, detailing how ICSs will become operational — I understand it is “changing almost weekly” as NHSE adapts it after consultations with stakeholders.

There is understood to be a timetable within it, listing which NHSE powers will be delegated to ICSs and when. Some of the thorny issues, such as specialised, may be held back until 2024. The timing for the transfer of other powers, such as commissioning for dentistry, ophthalmology and prison services, are still under discussion.

The current view is ICSs could choose to take on these services on a voluntary basis from April 2022, but will be given a clear deadline by which they must do so.

However, this voluntary first approach is causing much anxiety as ICSs begin thinking through how it will work. Regional NHSE teams currently carry out NHSE-commissioned work, which means a small number of people have the relevant knowledge and skills.

If these teams are hollowed out — either by leading ICSs poaching staff, or people choosing to leave as their role diminishes — less advanced ICSs fear they will be left with no support when they are ready to assume these powers.

Having spoken to system leaders, I expect this plan to be modified before publication, not least because NHSE has been praised for truly listening to leaders on legislative changes this time round.