NHS Reset is a new NHS Confederation campaign to contribute to the public debate on what the health and care system should look like in the aftermath of the COVID-19 pandemic.
In this blog, part of a series of comment pieces from NHS Confederation members and partners, Simon Trickett discusses the Integrated Care Systems Network newly published report and shares his vision of the future NHS.
I was involved in a very stimulating and important discussion with a number of other system leaders a couple of weeks ago which led to the publication of today’s report from the Integrated Care Systems Network. It’s an ongoing conversation, and is certainly not at the final stage in terms of definitive conclusions by any stretch, but it’s important to put current thinking on paper for others to see and to move the debate and the work forwards.
As you might imagine, there is consensus in some areas and a mixed view on others, but leaders are all keen that whatever structure of health service emerges, they want to get there sooner rather than later. Personally, I am in favour of a ‘third way’ approach and would like to find common ground in a system that includes providers, commissioners, and works in an integrated way with other partners such as local authorities.
It does mean that there needs to be fresh thinking and a new approach in some areas. For commissioning, this means clinical commissioning groups (CCGs) evolving and adapting to new roles that the system needs us to play and to move away from some of the traditional approaches. I know many of my CCG colleagues recognise the need to evolve and adapt and indeed already are. CCGs have been on a journey; in my patch alone it has been going on for four years and has now resulted in a full merger of four CCGs. CCGs have been incrementally evolving but now this needs to happen at pace if we want to move forward real integrated working at system level.
The new emphasis must be on the enabling and facilitating role commissioners can play, taking the best of commissioning into system planning, and we need to move away from the old style of specifying, procuring and contracting. The commissioning sector needs to adapt or change will be imposed on it and there’s a real challenge for us to show that we can add value in new ways moving forwards. From a personal perspective, I think that it’s also vital that we don’t lose what’s important in commissioning, especially around understanding local needs but also local scrutiny, coordination and partnership working. If we abandon too much of this, in a few years I think that we would be redesigning systems to include that local coordination, so our challenge is to adapt and do that now.
Many CCGs are already adapting to work successfully at integrated care system (ICS) level, and recognise the responsibility to develop smaller/ leaner structures. We need to devolve some functions and resources to empower integrated care providers to design the right pathways and service access, working with partners to emphasis pathway re-design and empower others in the system to lead change. We have spent a lot of time in recent years trying to prioritise supporting operational integration of care, aligning community teams with primary care networks and social care and other professionals.
As a system, we now need to turn our attention to what sits behind it. As system leaders we also have a role to confirm and challenge at a local level, but most importantly we need to enable change that makes best use of taxpayers investment and gets the very best services and outcomes for patients. We have been really fortunate during COVID-19 to have support and additional resources to provide as much capacity and access to services that we could manage, with the financial aspects of that taking a back seat. That can’t last forever though, and value for money and financial control will be a big part of the remainder of the year. There are clearly a range of conversations underway about what the financial settlement for the NHS will be over the longer term but where we need change from the centre is around the current financial frameworks. From my experience these are the biggest barriers to great ICS working and where we have managed to move away from old style PBR type contracts has been where there has been the most progress. Getting the money side is crucial, and if systems are given proper system-control totals that move accountability to system rather than organisational level for financial allocations, the levers for systems at their disposal would be greater.
But it’s not just about commissioners, it has to be about commissioners and provider organisations working together, responding to and meeting local needs within the resources available. In my vision for the future I personally would like to see a single integrated care provider model at place level, with system coordination and facilitation around that, particularly with a focus on properly involving other partners in a collective effort to improve health and wellbeing of local populations. Systems could then be given national outcomes to follow with additional outcomes and priorities added locally. So, we now need the provider side to consolidate and to change and for strong integrated care providers to emerge. In some areas this is going to require a culture change - we need organisations to stop protecting their organisations and to focus on system working and meeting local needs as their purpose; the old way of working needs to change now and COVID-19 has shown us what a reshaped, exciting and integrated future could look like.
Simon Trickett is chief executive of NHS Herefordshire and Worcestershire CCG and STP/ICS lead. Follow them on Twitter @HW_CCG
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