The NHS is once again under intense scrutiny as the focus shifts from covid to ambitious targets for elective recovery. Progress in achieving these targets is being overseen by delivery units in No.10, the Treasury and NHS England with ministers closely involved.
Responsibility for delivery rests with integrated care systems and the organisations within these systems. Guidance from NHS England has set out an intention to devolve decision-making to ICSs and reduce external oversight and regulation of their activities.
How then will the central scrutiny of NHS performance be reconciled with devolution? In a new report commissioned by the NHS Confederation, I draw on interviews with leaders in the NHS, local government to suggest some answers.
If ICSs are to succeed, two conditions must be met. First, ICSs must rapidly develop the capabilities needed to take on the role set out for them. And second, the authorising environment in which ICSs work must change.
In a taxpayer-funded service, upwards accountability for performance is a given. How accountability is exercised is what matters if the NHS is going to operate differently in future.
The starting point is that ICSs should be held to account for delivering a small number of national and local priorities. These priorities should be expressed as whole system targets and reflect the core purposes of ICSs including improving population health and tackling inequalities. Local priorities are vital because the challenges facing ICSs vary and to reassure partners that the issues of concern to them are receiving attention.
Transparency needs to go hand in hand with devolution. ICSs should be assessed based on their performance in delivering care and improving outcomes. Public reporting of data enables ICSs to see how they are doing against their peers and appeals to a natural competitiveness to improve.
Funding should be allocated to ICSs on a population basis and not tied to specific deliverables. In turn, ICSs should devolve funding to place-based partnerships with resources only being retained by the system when agreed by partners. Maximum devolution of funding will enable those responsible for delivering care to decide how best to improve outcomes.
ICS leaders are clear that a regime of earned autonomy, as proposed by NHS England, would not be helpful. In their view, there should be an assumption of autonomy with freedoms being constrained only when performance challenges are encountered.
The aim should be to work towards proportionate accountability involving light touch oversight of well performing systems and rules-based intervention in others. When intervention is needed it should take the form of support provided by peers from within an ICS or outside, with further measures used only in extremis.
A common refrain from ICS leaders is the need to move from a ‘parent to child to adult to adult’ relationship in interactions between ICSs, the centre and regions. This means changing cultures and behaviours which do not sit comfortably in an NHS committed to collaboration, partnership and mutual respect.
Don Berwick’s report in the wake of the Mid Staffordshire inquiry warned against the toxic effects of fear and blame, arguing that the NHS should commit itself to continuous improvement and learning. Amanda Pritchard’s promise that NHS England should exemplify in its work the behaviours needed across the NHS is a welcome and necessary first step in a cultural reset.
ICS leaders argued that the number of staff in regional offices should be reduced substantially. By employing fewer more senior and experienced people, they felt that regional offices would be able to provide more effective support when needed and reduce work that adds little value.
ICS leaders were clear that at the centre, national programmes should be limited to the most important priorities. They also made a plea for greater coordination of these programmes, which are often experienced as disjointed, overlapping and lacking in understanding of local pressures.
Close alignment between NHS England and the Department of Health and Social Care is another requirement. Under Simon Stevens’ leadership, NHS England exercised greater independence, but ministers are now clawing back some of the territory lost after the Lansley reforms. The use of joint teams of DHSC and NHS England staff is an example of how alignment at the centre is being addressed.
An unresolved question is the future of regional offices. Some of those interviewed pointed to the risk of adding another level of hierarchy if regional offices and ICSs co-exist. Others argued that a much bigger risk would be losing the expertise that regional offices have demonstrated before ICSs have developed the necessary capabilities.
One way forward would be to establish a joint review by leaders from different parts of the NHS to work through these issues, taking account of regional arrangements for public health and social care and how they relate to regional offices and ICSs. This would be a tangible example of the aspiration of NHS England to co-produce guidance and policy with NHS leaders and other partners.
To return to the starting point, a major challenge in acting on these proposals is the close involvement of ministers in overseeing performance and checking progress. The best safeguard against micromanagement from the centre is for ICSs demonstrate they have the capabilities to deliver measurable improvements in patient care and population outcomes.
Where appropriate, they and national leaders should push back on interventions that run counter to devolved decision making. Partnership with local authorities and meaningful engagement with people and communities are the best way of ICSs earning a mandate to push back.
Ongoing work by NHS England on a new operating model provides an opportunity to develop the cultures and structures for ICSs to succeed based on the ideas in my report.
Professor Sir Chris Ham is co-chair of the NHS Assembly and former chair of the Coventry and Warwickshire Integrated Care System. Follow him on Twitter @profchrisham
This post was first published by the HSJ.