Just weeks ahead of the promised publication of a new 10-year Plan for the NHS in England even those closest to the process seem unclear on what it might contain. A recent article by the chief executive of a non-profit outfit known as Curia, which claims to be relatively well informed, tells us the Plan will involve:
“… not a fully centralised NHS – nor a return to localism – but something in between: a regional model. Think 7 to 12 regional commissioning authorities, likely based on NHS England’s former regions, absorbing the responsibilities of the current 42 Integrated Care Systems.”
If we assume this is anywhere near correct, it raises the question of why ICBs are now being put through all of the costly convulsions required to merge smaller ICBs, reorganise themselves to reduce from 42 ICSs into just 28, and slash their staffing and overhead costs – only to face yet another massive reorganisation as soon as they have done it. Nothing could be more calculated to enrage the management who are made to look stupid as well as the staff facing the consequences on the ground. Indeed if Curia is right, the larger “plan” would be announced while the ICBs are already in turmoil.
This raises another question: why was NHS England encouraged to publish its Model Integrated Care Board Blueprint 1.0 (for remodelling ICBs and divesting them of some of their functions) early in May, if within a few weeks the ICBs are to be effectively dumped altogether by the 10-year Plan, to make way for less than half the number of “regional commissioning authorities”?
Admittedly, the Blueprint (apparently “developed by a group of ICB leaders from across the country”) is clear as mud. It is largely a verbal soup, made up of obscure jargon and abstractions, and focuses on transferring some ICB functions to “providers” or to “neighbourhood” organisations or “regional teams”.
However, what this would mean in practice is far from clear. One of the few concrete statements in the Blueprint comes in the Introduction, when it declares:
“We are sharing this blueprint with you today without the corresponding picture of what the future of neighbourhood health will look like or the role of the centre or regional teams.”
Reading between the lines, it’s clear the Blueprint itself is proposing a substantial change. It seems to be attempting to reinvent ICBs as a new incarnation of the Primary Care Trusts (PCTs) – the bodies which 20 years ago held the purse strings as the local NHS “commissioners” at the centre of New Labour’s costly and wasteful experiments with creating a competitive ‘health care market’ in England.
Much of the Blueprint’s focus on “strategic commissioning” and on the need for ICBs to “shape the local market,” and “Introducing and encouraging new [private sector?] providers where gaps exist in the market” echoes much of the unreadable nonsense rolled out back in the mid 2000s under the heading of “World Class Commissioning:” indeed it is specifically mentioned as a model on page 17.
The dense verbiage back in the 2000s was cover for a harsh reality: World Class Commissioning meant the PCTs divesting themselves of any remaining directly-provided services, and contracting out community health and mental health services – most often to private sector or non-profit “social enterprises.”
World Class Commissioning meant privatisation: large numbers of NHS staff were pushed out of the NHS and into the none-too-tender control of employers intent on delivering profits (or surpluses) while also keeping contract prices low. PCTs’ performance was assessed on the extent to which they could bring in private providers to create a local competitive market.
Today’s ICBs have no directly-provided services: but damage can still be done where they drive further outsourcing. We have already seen one ICB (Bath Swindon and Wiltshire) hand an enlarged £1 billion-plus contract for community health services to a private-equity-owned company, in defiance of the Labour government’s stated aim to bring outsourced services back in-house.
The Blueprint is vague on many issues, but quite clear in advocating that – despite their name – the ICBs should NOT be integrating services, but need instead to evolve as commissioners, firmly on the purchasing side of a sharpened purchaser/provider divide, and contracting rather than collaborating with NHS and other providers.
It insists: “ICB staff will need to learn how to proactively manage and develop the provider market, using procurement and contracting levers to incentivise quality improvement and innovation.”
It goes on: ICBS must “develop into sophisticated and intelligent healthcare payers … This will need to include commercial skills for innovative contracting and managing new provider relationships.”
This blast from the past fits in with Wes Streeting’s ambition to re-run many of the policies from peak Blairism, and its costly experiments with markets for health care in place of planning.
It strikes a very different note from NHS England chief executive Sir Jim Mackey, who told the Health Service Journal in April that he supports the focus on providers rather than commissioners, and looks forward to the establishment of “provider-led accountable care organisations” that would take on responsibility for organising care for their local population.
Even while he used the words, Mackey said he was also keen to “change the terminology” to avoid using the term “accountable care.” It has been most commonly used in the US to describe groups of doctors, hospitals, and other health care providers, who come together to organise coordinated care at a fixed cost to older patients covered by Medicare. The domination of private for-profit providers in the USA adds a very different meaning.
Sir Jim’s predecessor Simon Stevens back in 2014 attempted to break down the instinctive rejection of “accountable care” as an “American” notion by campaigners and the wider public: but the efforts proved unsuccessful, leading to NHS England’s abrupt change of language from 2019 onwards to refer to “Integrated Care” instead.
Eight “Accountable Care Systems” (ACSs) were given the go-ahead by NHS England in 2017, but the extent to which they actually represented anything qualitatively new has always been questionable. Ironically one of the first NHS organisations to be approved as an ACS, Frimley Health, now seems set to be dismembered and split across three ICBs in the coming reorganisation. This shows that today’s priority is aligning reorganised ICBs with county and unitary councils, not the notion of ACSs.
Among the many points the Blueprint leaves vague is the extent to which the new-style ICBs would be in any way locally accountable of to the communities they cover.
The Lowdown consistently criticised the model of ICBs on the basis that – following on from the short-lived Sustainability and Transformation Plan (STP) ‘footprints’ that were announced in early 2016 – they represented a step away from any connection with or responsiveness to the needs and wishes of local communities, a theme we have returned to recently.
We can be sure that whatever the 10-year Plan’s proposals may be, there is unlikely to be any groundswell of popular opposition to fundamentally changing or merging ICBs, let alone to defend them – because vanishingly few members of the public are even aware they exist, and even fewer will have any positive impressions of what ICBs have done.
But scaling down, or scrapping ICBs, and replacing them with far fewer Regional bodies that will be even more remote from any local needs or concerns would still be a further negative step for accountability.
Regional control would make it even harder still for local public or NHS unions to get any advance notice of plans for service cutbacks, closures, exclusions, privatisation and exclusions of services currently provided by the NHS – and harder again to challenge them. It would knock back the fight for accountability that has developed as a vital strand of campaigning since the 1970s.
Patient groups, voluntary sector organisations, campaigners, trade unions and elected local politicians can only challenge (or engage with) policies if they are aware of them, and the Blueprint’s ambition of “co-producing strategy with communities, reflecting unmet needs and targeting inequalities” (p8) could only be achieved by sharing information with the wider public.
Even now it’s clear from the complete absence of almost any details on how ICBs and NHS trusts have been making the huge “savings” and so-called “efficiencies” that much of the discussion of this at board level is taken in private session or by committees that do not meet in public. This would be much worse again if a reduced number of Regions take control.
At present the Regions are not public bodies in the way the old Regional Health Authorities were until they were abolished by John Major’s government in 1995, or the 28 Strategic Health Authorities that replaced them from 2002.
Today’s Regions are purely internal sub-divisions of NHS England, predominantly bureaucrats appointed from the top down, working and meeting behind locked doors. They publish no papers, run no consultations, share no discussions. Their task is forcing ICBs and trusts into line.
So if the future of England’s NHS is in fact regional, it threatens to break up any remaining traces of accountability to local communities. With this goes any serious link with local government, which was a supposed strength of STPs and ICBs, even though the links were only partial and one-sided.
It’s obvious that if just 7-12 regions are the most ‘local’ bodies taking decisions, none of the local county or unitary councils they cover will have any meaningful influence on decisions, and the needs of any and every community would be even less considered.
Jim Mackey, advocating a “big consolidation” of ICBs as a way to balance the books after admitting spending has been “maxed out”, told the HSJ in April that the changes had to avoid creating ICBs “so big you can’t have good relationships with councils”.
A switch to regional control would fall into exactly that danger.
The rapid-paced and often contradictory series of announcements of organisational change in the NHS since January could be topped off by a 10-year Plan that effectively contradicts all of them, and leaves Sir Jim and other recently appointed NHS leaders looking ridiculous.
But even if the Plan does not go this far there are strong reasons why campaigners need to find ways to work with local councillors and MPs to demand the new system it ushers in includes the establishment of genuine accountability to patients, public and staff as well as elected politicians in local communities, rather than riding roughshod over their needs and concerns.
But given what has happened so far since Labour was elected last July, who would bet against Wes Streeting publishing a 10-year plan next month that would brush all these concerns aside and threaten to impose a new model of NHS that nobody wants, regardless of the impact on morale of frontline and other NHS staff as well as the managers who would once again be pressured to shut up and implement it?
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
Just weeks ahead of the promised publication of a new 10-year Plan for the NHS in England even those closest to the process seem unclear on what it might contain. A recent article by the chief executive of a non-profit outfit known as Curia, which claims to be relatively well informed, tells us the Plan will involve:
“… not a fully centralised NHS – nor a return to localism – but something in between: a regional model. Think 7 to 12 regional commissioning authorities, likely based on NHS England’s former regions, absorbing the responsibilities of the current 42 Integrated Care Systems.”
If we assume this is anywhere near correct, it raises the question of why ICBs are now being put through all of the costly convulsions required to merge smaller ICBs, reorganise themselves to reduce from 42 ICSs into just 28, and slash their staffing and overhead costs – only to face yet another massive reorganisation as soon as they have done it. Nothing could be more calculated to enrage the management who are made to look stupid as well as the staff facing the consequences on the ground. Indeed if Curia is right, the larger “plan” would be announced while the ICBs are already in turmoil.
This raises another question: why was NHS England encouraged to publish its Model Integrated Care Board Blueprint 1.0 (for remodelling ICBs and divesting them of some of their functions) early in May, if within a few weeks the ICBs are to be effectively dumped altogether by the 10-year Plan, to make way for less than half the number of “regional commissioning authorities”?
Admittedly, the Blueprint (apparently “developed by a group of ICB leaders from across the country”) is clear as mud. It is largely a verbal soup, made up of obscure jargon and abstractions, and focuses on transferring some ICB functions to “providers” or to “neighbourhood” organisations or “regional teams”.
However, what this would mean in practice is far from clear. One of the few concrete statements in the Blueprint comes in the Introduction, when it declares:
Reading between the lines, it’s clear the Blueprint itself is proposing a substantial change. It seems to be attempting to reinvent ICBs as a new incarnation of the Primary Care Trusts (PCTs) – the bodies which 20 years ago held the purse strings as the local NHS “commissioners” at the centre of New Labour’s costly and wasteful experiments with creating a competitive ‘health care market’ in England.
Much of the Blueprint’s focus on “strategic commissioning” and on the need for ICBs to “shape the local market,” and “Introducing and encouraging new [private sector?] providers where gaps exist in the market” echoes much of the unreadable nonsense rolled out back in the mid 2000s under the heading of “World Class Commissioning:” indeed it is specifically mentioned as a model on page 17.
The dense verbiage back in the 2000s was cover for a harsh reality: World Class Commissioning meant the PCTs divesting themselves of any remaining directly-provided services, and contracting out community health and mental health services – most often to private sector or non-profit “social enterprises.”
World Class Commissioning meant privatisation: large numbers of NHS staff were pushed out of the NHS and into the none-too-tender control of employers intent on delivering profits (or surpluses) while also keeping contract prices low. PCTs’ performance was assessed on the extent to which they could bring in private providers to create a local competitive market.
Today’s ICBs have no directly-provided services: but damage can still be done where they drive further outsourcing. We have already seen one ICB (Bath Swindon and Wiltshire) hand an enlarged £1 billion-plus contract for community health services to a private-equity-owned company, in defiance of the Labour government’s stated aim to bring outsourced services back in-house.
The Blueprint is vague on many issues, but quite clear in advocating that – despite their name – the ICBs should NOT be integrating services, but need instead to evolve as commissioners, firmly on the purchasing side of a sharpened purchaser/provider divide, and contracting rather than collaborating with NHS and other providers.
It insists: “ICB staff will need to learn how to proactively manage and develop the provider market, using procurement and contracting levers to incentivise quality improvement and innovation.”
It goes on: ICBS must “develop into sophisticated and intelligent healthcare payers … This will need to include commercial skills for innovative contracting and managing new provider relationships.”
This blast from the past fits in with Wes Streeting’s ambition to re-run many of the policies from peak Blairism, and its costly experiments with markets for health care in place of planning.
It strikes a very different note from NHS England chief executive Sir Jim Mackey, who told the Health Service Journal in April that he supports the focus on providers rather than commissioners, and looks forward to the establishment of “provider-led accountable care organisations” that would take on responsibility for organising care for their local population.
Even while he used the words, Mackey said he was also keen to “change the terminology” to avoid using the term “accountable care.” It has been most commonly used in the US to describe groups of doctors, hospitals, and other health care providers, who come together to organise coordinated care at a fixed cost to older patients covered by Medicare. The domination of private for-profit providers in the USA adds a very different meaning.
Sir Jim’s predecessor Simon Stevens back in 2014 attempted to break down the instinctive rejection of “accountable care” as an “American” notion by campaigners and the wider public: but the efforts proved unsuccessful, leading to NHS England’s abrupt change of language from 2019 onwards to refer to “Integrated Care” instead.
Eight “Accountable Care Systems” (ACSs) were given the go-ahead by NHS England in 2017, but the extent to which they actually represented anything qualitatively new has always been questionable. Ironically one of the first NHS organisations to be approved as an ACS, Frimley Health, now seems set to be dismembered and split across three ICBs in the coming reorganisation. This shows that today’s priority is aligning reorganised ICBs with county and unitary councils, not the notion of ACSs.
Among the many points the Blueprint leaves vague is the extent to which the new-style ICBs would be in any way locally accountable of to the communities they cover.
The Lowdown consistently criticised the model of ICBs on the basis that – following on from the short-lived Sustainability and Transformation Plan (STP) ‘footprints’ that were announced in early 2016 – they represented a step away from any connection with or responsiveness to the needs and wishes of local communities, a theme we have returned to recently.
We can be sure that whatever the 10-year Plan’s proposals may be, there is unlikely to be any groundswell of popular opposition to fundamentally changing or merging ICBs, let alone to defend them – because vanishingly few members of the public are even aware they exist, and even fewer will have any positive impressions of what ICBs have done.
But scaling down, or scrapping ICBs, and replacing them with far fewer Regional bodies that will be even more remote from any local needs or concerns would still be a further negative step for accountability.
Regional control would make it even harder still for local public or NHS unions to get any advance notice of plans for service cutbacks, closures, exclusions, privatisation and exclusions of services currently provided by the NHS – and harder again to challenge them. It would knock back the fight for accountability that has developed as a vital strand of campaigning since the 1970s.
Patient groups, voluntary sector organisations, campaigners, trade unions and elected local politicians can only challenge (or engage with) policies if they are aware of them, and the Blueprint’s ambition of “co-producing strategy with communities, reflecting unmet needs and targeting inequalities” (p8) could only be achieved by sharing information with the wider public.
Even now it’s clear from the complete absence of almost any details on how ICBs and NHS trusts have been making the huge “savings” and so-called “efficiencies” that much of the discussion of this at board level is taken in private session or by committees that do not meet in public. This would be much worse again if a reduced number of Regions take control.
At present the Regions are not public bodies in the way the old Regional Health Authorities were until they were abolished by John Major’s government in 1995, or the 28 Strategic Health Authorities that replaced them from 2002.
Today’s Regions are purely internal sub-divisions of NHS England, predominantly bureaucrats appointed from the top down, working and meeting behind locked doors. They publish no papers, run no consultations, share no discussions. Their task is forcing ICBs and trusts into line.
So if the future of England’s NHS is in fact regional, it threatens to break up any remaining traces of accountability to local communities. With this goes any serious link with local government, which was a supposed strength of STPs and ICBs, even though the links were only partial and one-sided.
It’s obvious that if just 7-12 regions are the most ‘local’ bodies taking decisions, none of the local county or unitary councils they cover will have any meaningful influence on decisions, and the needs of any and every community would be even less considered.
Jim Mackey, advocating a “big consolidation” of ICBs as a way to balance the books after admitting spending has been “maxed out”, told the HSJ in April that the changes had to avoid creating ICBs “so big you can’t have good relationships with councils”.
A switch to regional control would fall into exactly that danger.
The rapid-paced and often contradictory series of announcements of organisational change in the NHS since January could be topped off by a 10-year Plan that effectively contradicts all of them, and leaves Sir Jim and other recently appointed NHS leaders looking ridiculous.
But even if the Plan does not go this far there are strong reasons why campaigners need to find ways to work with local councillors and MPs to demand the new system it ushers in includes the establishment of genuine accountability to patients, public and staff as well as elected politicians in local communities, rather than riding roughshod over their needs and concerns.
But given what has happened so far since Labour was elected last July, who would bet against Wes Streeting publishing a 10-year plan next month that would brush all these concerns aside and threaten to impose a new model of NHS that nobody wants, regardless of the impact on morale of frontline and other NHS staff as well as the managers who would once again be pressured to shut up and implement it?
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
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