Another step towards integrated care - but pitfalls remain | Niall Dickson

Niall Dickson

There is widespread support for the vision of the NHS long-term plan and the key question is whether we can deliver the changes required locally to make it a reality, writes Niall Dickson, chief executive of the NHS Confederation, as he weighs up the prospects of progress for integrated care systems.

Based on the views of front-line leaders across NHS trusts, clinical commissioning groups and integrated care systems, we at the NHS Confederation set three key tests for the plan: is it deliverable and affordable? Does it enable care to shift out of hospitals and closer to people’s homes? Does it give local leaders the freedom they need to shape and develop the services required in their area?

Collated framework

Following the publication last week of the implementation framework for the plan, we can be more confident that the answer is yes. While there are some key issues still to resolve, the framework moves us closer to creating the conditions needed for local systems to succeed. Our members will now turn to collating the initial local system plans that will be required by September.

The framework followed the Commons health committee’s report on NHS England’s consultation on proposed legislative changes to facilitate system working. It was good to see the committee accepting many of our recommendations and ruling out another top-down reorganisation.

Both the framework and the committee’s report are useful steps towards a better operating environment and help to address many of the workarounds that local leaders are operating under.

It is encouraging that both reports recognise the dangers of concentrating more power at the centre and the importance of handing local health and care organisations the freedoms they need to work effectively together.

Pitfalls remain

The task facing NHS England/Improvement is to make sure the conditions are right, both nationally and regionally, to support local leaders to make these important changes.

Local organisations and their teams know their communities should be given the latitude to shape services, in partnership with local people. The focus on system working, place-based partnerships and a less centralised structure should help to make this possible.

Of course, significant tensions remain. Everyone is signed up to the idea of joined-up care closer to people’s homes, tackling health inequalities and improving prevention, and believe these should be at the heart of local plans. This will require large and consistent investment in new models of care, while sustaining an already pressurised acute sector.

At the same time, we must be careful of the potential dichotomy between what national bodies deem to be ‘must-dos’ and the need to hand genuine autonomy to local leaders. It must be a case of creating a balance between centrally determined priorities and solutions at a local level. The framework signals the right intentions on this, but we will need to see this followed through.

There are other potential pitfalls, too.

Signs of progress

We must be aware that every local system is at a different stage of its development – and some will need more support than others. For some at least, the deadline for submitting initial plans by September is tight.

For those that are more advanced in their thinking and execution, constructing a five-year plan will probably involve building on previous strategies. But in some areas, a slower pace may be preferable, to allow all members of the partnership to feel that it is not being imposed by NHS organisations without local input.

There should therefore be some flexibility so that longer conversations can take place with communities, staff, councils and voluntary sector providers. True engagement has to be a vital part of this process.

As there are still unanswered questions, NHS Clinical Commissioners, part of the NHS Confederation, is working with NHSE on how clinical commissioning will evolve as system working is developed. One question, for example, is which activities might need to stay with a CCG, and which might become a function of an integrated care system.

And of course, a series of fundamental, mission-critical issues remain unresolved.

The unfinished business around capital spending, training and education budgets, public health and social care will need to be tackled in spite of all the other uncertainties. Each one is enough to undermine delivery of the LTP, as is the already considerable workforce challenge.

Without the right staff in place, we will not deliver the LTP, whatever our good intentions.

The glass is half full, not half empty – and we are seeing signs of progress, with pioneering changes to the way services are delivered.

Key to our future will be breaking down the legislative and other barriers that could stand in the way of local leaders – both these reports are another important step along the way.

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

First published in the HSJ, 4 July 2019. 

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