‘Big consolidation’ of ICBs coming, says new NHSE chief exec

In his first interview as NHSE’s “transition chief executive”, Sir Jim Mackey said the governnment’s decision to cut ICB running costs by 50 per cent by October had already lead to “a lot of the smaller [ICBs]… talking to each other about merger”.

As well as addressing the fate of ICBs, Sir Jim told HSJ  he “absolutely” supported the establishment of provider-led accountable care organisations in the NHS but that only parts of the NHS could successfully deliver them.

He also pledged to “stick up for the NHS” in disagreements with ministers.

Sir Jim said NHSE was “trying to resist” insisting ICBs combine or merge to cover a minimum population, but he added: “I think people are doing that naturally and the conversations at the minute look like we’re going to have quite a big consolidation.”

Currently system populations served by ICBs range from 3 million, down to 500,000.  Sir Jim noted changes needed to avoid creating ICBs “so big you can’t have good relationships with councils”, and to consider mayoral combined authority boundaries, however.

He said NHSE would shortly set out “things [ICBs] can deprioritise or find different ways of doing”.

These will largely concern provider oversight. NHSE will “find a way of telling [ICBs] ‘you don’t need to do that, the provider will take responsibility’. There’ll be an oversight system that allows you to not have 20 people or 30 people doing that.”

A government health bill, whose timing is not confirmed, would remove some legal duties from ICBs, making it easier to reduce costs, the new NHSE CEO said.

Sir Jim said control over some specialised commissioning was still being delegated from NHSE to ICBs as planned. However, he said the right level for commissioning different specialised services would have to be reconsidered as part of the changes in coming months ahead of the health bill.

The CEO confirmed NHS regional teams will remain and take on a greater provider performance management role as ICBs drop it. The nature of their role and configuration was yet to be confirmed, he said, but suggested they would have some separation from the centre of the NHS, which is due to move into the Department of Health and Social Care.

A letter from the NHSE CEO to local leaders today is due to set out more details of how ICB staff reductions will be handled.

Not everywhere ready to be an ACO

In the wake of news of 50 per cent cuts to ICBs, some provider leaders have suggested they are well-placed to take on much more responsibility for organising care for their local population, a model often described as an “accountable care organisation”.

It is an approach which has been pursued by Northumbria Healthcare Foundation Trust, where Sir Jim was previously the long-standing CEO. The trust is heavily involved in community, primary and social care.

Sir Jim, whose substantive role is now CEO of neighbouring Newcastle Hospitals, said he was “absolutely” behind the ACO idea — although “we need to change the terminology” – but he cautioned: “I can [only] think of 10 places that could do that really well.”

He said: “I’ve had a few [trusts] lobby me in the last few weeks to say, ‘I think we’re ready now to go for this’. And in a couple of them you would believe they could. But there are an awful lot of other places, especially where we’ve got a lot to do on the money, or some terrible structural issue going on, where you would look at and think, ‘no’.”

Sir Jim also cautioned that the needs of different geographic areas should drive the choice of structure. 

“We’ll be saying we really want to ramp up neighbourhood care. We really want to do more about quality of care for the frail elderly or children or different segments of society, with some rules and parameters, and then let people… work out their way of delivering it.”

Sir Jim said: “In some places, community providers might be the strength, in some places it might be a GP federation, or mental health [providers which] have a lot of strength in community services.”

Anxiety on groups and collaboratives

Asked about the growth of hospital groups, Sir Jim said the current “political team” at DHSC were “anxious on large conglomerates, big groups, big, merged organisations that become desensitised to local need, and become self-serving – more about their own needs than population need. And I can see a bit of that”.

Collaboratives have also been told to cut running costs by 50 per cent. And Sir Jim said he had been “getting quite a lot of direct challenge from political colleagues who keep hearing the [NHS] leadership community [spends its time] in lots of external meetings”.

“And I’ve moaned about that myself as a chief exec – lots of necessary collab meetings, lots of ICB meetings, place meetings,” he said. “Now’s the time not to lose all that completely but to rebalance a bit and get connected to your organisation, the thing you’re legally accountable for, and… let’s make sure we’re actually on the tools all the time.”

He cautioned, however, that the NHS should be careful not to “over correct [and go] back to the old [foundation trust] baronies”, and noted there were some “benefits of the last few years”.

“[Trusts] aren’t slugging it out through the newspapers, they’re not having big legal disputes with each other about service configuration or competition and choice,” which were “embarrassing” and used to take place in some areas, he said. “[NHSE] will be continuing to make judgements about provider organisations and the extent to which they’re still working well with colleagues — not letting each other down and planning together. But you don’t have to do everything with everybody else.”

Sir Jim also defended his own background, saying: “For people who are saying I’m entirely acute orientated: I’ve run community services since I came into the NHS in 1990 in different ways. My first job was a community finance manager. I’ve run bits of mental health through that period. I’ve run a big primary care business.

“So, I understand the point and I understand the anxiety of people thinking, ‘this is all about the big acutes’. It’s not. It’s about the patient, and if people can find ways of delivering the best result by a few different kinds of organisations working together, absolutely. Let’s try that.”