ICSs face irrelevance unless the devolution frenzy is curbed

Integrated care systems are, of course, not finished being born. Labour is advanced but will not conclude until 2023 when their Byzantine structures have been erected and, the hopefully more straight-forward, five-year plans signed off.

The principle of integrated care is a fine one and it was time to end the NHS’s experiment with an internal market. However, even before the first ICSs emerge blinking into the light, the seeds of their potential destruction are being sown.

The most important of those seeds are as follows.

There are too many ICSs in some parts of the country, especially the South West and Midlands. This means that effective integration will struggle due to limited resources, leadership capacity and ability to influence large providers. It is also a problem widely acknowledged at the centre and within the regions. 

The proposed structure for ICSs is overly complex, consisting of a partnership board with little statutory power, which is meant to give strategic direction to an executive board which in practice will be held accountable for all decisions, but which is also meant to give up as much power and money as possible to “place based” entities which remain ill defined and have no statutory standing.

Then there are the nascent provider collaboratives – which cut across places and even some systems and who some influential figures suggest may be the real power in the land.

In some areas structures are being constructed which add additional players still. That is a heck of an organogram before you have added the existing infrastructure of trusts, GPs and the myriad other care organisations which actually treat and look after people. Where primary care networks fit into all this, hopefully Claire Fuller is about to tell us.

All parties within this mixed-up confusion have been told their hand will be on the tiller. This has encouraged an understandable enthusiasm in health and care stakeholders, particularly those groups who feel they have been starved of cash and attention in the past. Hardly a day passes without HSJ receiving a press release from one sector or another declaring they must be given even greater control and autonomy to make the reforms really fly.

Any suggestion this Panglossian situation might result in a struggle for power is met by accusations of cynicism and claims the new spirit of co-operation will carry all before it. That seems a triumph of hope over experience. Those championing the reforms must be very careful of over-promising control. It is a very quick route to disengagement, especially among non-NHS partners, as clinical commissioning groups and sustainability and transformation partnerships both found.

In the name of local devolution and “subsidiarity”, 1,000 flowers are blooming – something Simon Stevens said the NHS should avoid at all costs – and, as a result, the government is creating a machine whose gears cannot help but grind against each other, spewing out “postcode lotteries” as a result. This idea used to terrify politicians. It still should – poll after poll shows the public dislike it even more than poor quality care.

However, the deepest flaw in the reforms as they stand is that since they emerged as the direction of travel in 2016 – and even since NHS England formally requested legislation to establish them in late 2019 – the times could not have changed more.

Fighting the last war

Horizontal and vertical integration, and greater collaboration, remain, in theory at least, a promising idea. But they do not directly address the two main challenges of the next two to three years: recovering elective performance or tackling inadequate social care provision.

Nor do they pass muster at a time when there are 6 million and growing on the elective waiting list, staff exhausted from combating a pandemic, and with many in and around the government keen to use the NHS’s travails as a stick to beat it with.

This is not the fault of ICSs. But they will be in charge and, as a result, will get the blame.

Having embarked on these changes pre-covid, the NHS finds itself in a bind. There was little option but to push on. The Heath Robinson Lansley reforms had already been half dismantled, and what was left was being roundly ignored. A vacuum needed to be filled.

That, however, does not mean what was conceived of before the pandemic is still fit for purpose. The sooner this is recognised, and steps taken to better align the reforms to the challenges ahead, the better.

There should be no shame or embarrassment to adjusting course – however much the critics may carp. The length of time it takes to conceive and implement NHS reforms inevitably means they all find themselves, at least in part, fighting the last war.

Learning the lessons of history

The alarm bells about CCGs were sounded even before they were created – and not just by the coalition’s enemies. The penny finally dropped with everyone, including government, that CCGs were the wrong fit for the times from about 2014. In February 2017, HSJ wrote about how to give CCGs “a good death” – but it was five years before they found themselves knocking on heaven’s door.

The fear of being accused of another “top-down reorganisation”, especially after such a bruising legislative battle to get the Lansley reforms implemented, was crippling. Twinned with austerity it made for a dangerous combination.

And here we are again. A major set of reforms being introduced at a time of severe financial challenge. Yes, these reforms, deservedly, have more support, but they also face a degree of performance and operational pressure several times greater.

It is time for the government and NHSE to take a good look at the inherent weaknesses of ICSs as they emerge and make specific plans to mitigate them.

Having (nearly) got its bill through Parliament, the centre should go through with the creation of ICSs in July, but should suspend the current mantra which is requiring ICSs to rapidly delegate most of their responsibilities and budget to a complex cast of subsidiary collaboratives, committees and partnerships.

Instead, it should get behind ICSs in their first year – and try to capitalise on them as potentially the most effective regional planning bodies since strategic health authorities, which have the added advantage of possessing local government in their DNA too. Put them to the test by asking them to focus on churning through electives and bringing the emergency care/discharge/social care pathway under control, rather than another round of structural tweaking.

In parallel, government and NHSE should reconsider why such a plethora of different governance arrangements are springing up around the country and ask how that will really help with successful service change and – yes – real integration, in the years to come.