NHS Voices blogs

Flexible regulation and oversight key to successful system working

Ensuring systems are both supported and held to account will be crucial to the effectiveness of integration.
Annie Bliss

24 May 2021

As the NHS begins to recover from COVID-19, health and care organisations working within integrated care systems (ICSs) will want to move quickly towards integration and system working, writes Annie Bliss, policy associate at the NHS Confederation.

Great strides have been made towards this, but as the Health and Care Bill progresses through parliament, there will be growing apprehension around system accountabilities. Ensuring systems are both supported and held to account will be crucial to the effectiveness of integration. This will require striking a balance between a permissive system of regulation and oversight that allows for local flexibility, and one that ensures national consistency.

Providing clarity

NHS England and NHS Improvement (NHSEI) has recently consulted on proposals for a new NHS System Oversight Framework 2021/22. This is an opportunity to provide clarity to system partners operating within the new ICS arrangements on their roles and accountabilities. The framework should be viewed as a stepping stone during a transitional year, before statutory duties are clarified in April 2022.

But NHS and other system leaders also need clarity now on accountabilities. As details of the bill emerge, a key concern for our members will be the Secretary of State’s increased powers to intervene in local service reconfigurations. The fear is that this could interfere with the commitment to work in a ‘system by default’ and in ‘letting local leaders lead’, as ICSs undertake the fundamental shift to statutory bodies.

A single point of focus

ICS leaders are clear that a central focus will be tackling health inequalities. The pandemic brought many inequalities into the spotlight and also exacerbated them, and this could be the single issue that can bring partners together. But this will require tailored approaches that recognise differing local priorities and system configurations. What works in West Yorkshire and Harrogate ICS, for example, may be worlds apart from what works in Dorset.

We must not lose focus on this, especially as the NHS begins to address the elective care backlog, with 5 million patients waiting to start treatment. NHSEI must ensure population health and inequalities stay at the top of the agenda, alongside elective care recovery, in the implementation of this oversight framework and planning guidance. There is a risk that the focus in the coming months will be on high-volume elective recovery, with more and more news stories chronicling the pain and stress people face as they wait for treatment.

Yet health inequality is the unifying issue for many system partners in ICSs and place-based partnerships. If we lose sight of that, and focus solely on short-term transactional care, there is a risk that we could jeopardise progress.

What is ‘well-led’?

Finessing the definition of ‘well -led’, as per the Care Quality Commission’s (CQC) terminology, will also be crucial to enable leadership teams to commit to long-term partnership working and tackling health inequalities. If the wrong definition of ‘well -led’ is used, it will encourage short-termism and could destroy partnerships. System leaders will watch with interest in the coming months as this definition and the wider role of the CQC in scrutinising ICSs is clarified.

Working together

The culture and relationships between place-based systems and individual organisations will be crucial to the success of the new system architecture, as well as between regional teams and national programmes. The system oversight framework clearly intends to create a permissive environment and regulators rightly want to foster a culture that supports quality improvement, integration and system working. But there must be understanding that behaviours and culture can be huge barriers to ICS development, and the cultures within the organisations overseeing the new system will be crucial.

What success looks like

The real measure of the success of ICSs will be in the difference they make to local populations, in particular the progress they make on health inequalities. Regulators will need to create a flexible locally-led culture in which ICSs are enabled to do so in the lead up to statutory ICSs. Getting regulation and oversight right now will be vital to make sure system working can thrive.

Annie Bliss is policy associate at the NHS Confederation. Follow the Confederation on Twitter @NHSConfed