The future is with us

The slogan of the next chapter in this story of a reorganisation that dare not be called a reorganisation is ‘System By Default’. The forthcoming document, out for discussion not diktat, will sum up current thoughts at the centre about how ICSs should develop.

Whatever we may think of the ideas emanating from the centre, if we are honest there is no overwhelming consensus within the service about the way forward.

This is hardly surprising as there is huge variation in the progress made towards integrated working at local level. In some parts of the country, new attitudes flourish and there is a real sense of common purpose even when there are significant financial and clinical challenges.

Those areas which are struggling not only face such challenges, they are systems with tensions, which lack a shared vision between primary and secondary care, have disengaged or warring local authorities and a host of other formidable obstacles, many of which manifest themselves through a lack of trust between the players. The world obviously looks very different if you are operating within such a difficult health and care economy.

But it would be a mistake not to take part in this debate and at least try to propose some solutions. Whether you like them or not ICSs are going to be the critical strategic and delivery drivers for the NHS Long Term Plan.

The unanswered questions, for now, are what powers should they have and how should they be exercised? What relationships should they have locally, regionally and nationally? If they are so vital, how can they be given the means not just to oversee a highly complex set of services, but to help bring about the most radical transformation ever attempted in the way health and care services are run?

The first issue must be around their relationship with the centre. It would be fair to say that there are considerable tensions, though again this is variable with one of the complaints being that there is no consistency in how the regional outposts of NHSEI see their role. There are complaints too of excessive interference or unreasonable demands for pointless information and overcomplex funding and reporting arrangements.

Simon and his team are clear that they want to decentralise to local systems and the thrust of the latest iteration is that the centre wants to reflect on its own processes and behaviours. In future the focus (and support) will be directed more towards systems and less towards organisations. There will be strong support for this decentralisation, but with that a demand for much greater clarity about who is going to be responsible for what and commitment for the behaviours that will underpin those responsibilities. 

With the decentralisation message comes the expectation that systems will performance manage their health economies. This in turn begs questions about their relationship with all the organisations within their patch. How will they move from gangs of volunteers to exercising oversight and holding ‘member’ organisations to account, and how will local government, very much volunteers in this endeavour, with different accountabilities, fit in to that?

And of course this is about much more than checking the operational routine, it is about having the clout to drive through reconfiguration and service change where that is in the interests of the whole population;  even where it does not have the support of all parties or institutions within the area.

Secondly and perhaps more mundanely, these fledgling outfits will need some resources if they are to be the drivers of transformational change. The centre has found a small sum to support the central teams within each one but if it is serious about this being the key delivery level for the plan they will need a much more serious level of investment, or rather a serious transfer of resources from central and regional functions.

Thirdly, we do need to nail down how we want to develop relationships with local government. In parts of England we have managed to develop pooled budgets, shared risks and, most important of all, joint services and projects that bring integration to life. But we are a long way from achieving anything like the potential of this. The view within local government remains that too often the STP and ICS movement has been more about sorting the NHS out than genuinely creating an integrated future. We will not solve this by imposing solutions from the centre, but there must be more we and other national bodies can do to create incentives and provide support to help make integration a reality.

Last, there is the legislation issue. We are all agreed another top-down reorganisation would be an unfortunate distraction – hence the important work NHSEI led before Christmas setting out a limited set of proposals to amend the current legal framework. There is a suggestion that the Government may wish to go further to strengthen the role and powers of integrated systems, and among some system leaders there would be support for at least exploring that. The trick though would be to create a framework in which we do not undermine what positive collaborations have achieved but create a system that can move at pace to deliver the transformation that is needed.

We will be consulting our members, including our new ICS Network, on the draft paper – please do let us have your thoughts and views on this. To state the obvious, unless we get the delivery vehicles right, the service will not be able to deliver for patients and for populations.

Niall Dickson is chief executive of the NHS Confederation. Follow him on Twitter at @NHSC_Niall.