The Integrator: Unite and rule

The top rungs of NHS England and Improvement have seen pretty dramatic changes in the last few months, and key executive roles have moved to single appointments across both.

It seems to be precipitating a real change in the regulatory approach already. 

In recent years, repeated promises to work across NHSE and I, and commissioners and providers, or doing business through systems, have tended to fall by the wayside once serious issues crop up. 

Lately though we’ve seen the seven new joint regional directors asked to balance, in the clearest fashion for many years, the finances of their chunk of England. The ask does not – on the surface at least – distinguish between commissioner and trust sector.

We’ve seen the RDs then pick up this gauntlet and throw it down again to their patches – apparently transacting this via systems, rather than organisations – and explaining starkly to sustainability and transformation partnerships and integrated care systems that they’ll have to bail out their neighbouring areas, just like it’s 2009 again. (Incidentally, one difficulty here is those wishing to get councils to put money in a local system bucket will find them more suspect when they realise the bucket can spill into their neighbour’s bucket.) 

Again, on the invidious task of slashing a fifth from capital spending plans, new envelopes have been handed out on an STP/ICS basis, with “providers to work together on an STP/ICS footprint to prioritise capital expenditure”, and STP leads asked to make new submissions, presumably after refereeing an unpleasant and tense fight over what’s left (by Monday, incidentally). One very unhappy trust chief executive reader comments: “The divide and rule approach of giving this mess to STPs… is reprehensible.”

And divide and rule, if that’s how you see it, is precisely the objective of restoring financial planning and control at regional and system level. The principle is that since the end of strategic health authorities, parts of the NHS which are overspending have not felt the consequence at a local level, all of it essentially being nationalised to someone in Leeds or central London to sort out. Now it is you or your neighbours – and your own beloved RD – who will feel the pinch as they did in the old days. Given the system working dimension, you could argue this is “unite and rule”.

In the less unpleasant arena of new requirements to spend a bigger share on primary and community health, a similar principle can be seen in recent planning guidance. Although each STP and ICS must meet this target by 2023-24, steps towards it can be shared year to year between each system in a region, creating wriggle room and regional discussion about spreading the impact. 

There are still many limits to the joint approach, of course. Trusts have their own hard control totals and provider sustainability funding, and, for most areas, a system control total is not published. Even the ICSs – I think Dorset may be the only exception – have declined the option of gambling their whole PSF as a system in 2019-20. Trusts and CCGs are still being measured largely as organisations, not systems.

But giving STPs and ICSs these hard edged jobs is a big step and could be a telling one, throwing their strengths or weaknesses into sharp focus. Despite the comparisons many have made, they are not set up like any health authority. In the words of one sensible new regional E/I recruit, the leadership and infrastructure of many systems is not “load-bearing”. Even for the strongest systems, these are new tests for an approach very light on rules and hierarchy, and heavy on collaboration and distributed decision-making.

Forever in chains

In perhaps another sign of the change about, the implementation framework for the NHS long-term plan was rather underwhelming. One intention (successful or not) was to signal that systems now have better revenue growth, and have been given some must dos, including financial balance, but beyond that have flexibility.

There was a change of tone, though, on foundation groups (aka hospital chains). It’s a policy that’s seen no great movement for a while but the framework promises “guidance for aspirant provider groups… followed by the new ‘fast-track’ approach to assessing transactions for groups”.

I’ve no idea the views of Amanda Pritchard, the imminently-to-start effective deputy at NHSE/I, but her Guy’s and St Thomas’ Foundation Trust has won much appreciation for successfully supporting trusts across the south east. But without taking them over. 

Legislation next steps

Some would look to legislation to empower systems – and/or, indeed, regulators – to force through the sorts of unpopular cross-organisational tasks discussed above.

The official position is that this is not the case and the proposals put forward by NHSE this year would help smooth locally-led change. I think this more or less stacks up – much more of a concern is that this very flexibility and absence of new legal status and powers leaves much scope and temptation for regulators, and on some issues ministers, to exert control.

The proposals so far have a broad endorsement from the Commons health and social care committee, but MPs do have a few concerns, as do organisations like NHS Providers and the Local Government Association.

NHS England and others have been working to try to iron out some of the disagreements, but it will save any further public pronouncements until a new prime minister is in place, since their view – despite their lack of a Commons majority – will be crucial.