Even before they gain any statutory powers some Integrated Care Systems are facing major problems, while others are concealing them by not fully revealing the state of play.
There are problems ahead in areas where ICS boundaries cross over the boundaries of local authorities. The White Paper proposes that ICSs should be coterminous with local authorities, but as the HSJ points out, almost 20 ICSs potentially breach this requirement, – from Cumbria and North Yorkshire in the north through to Essex, Surrey and Hampshire in the home counties.
In some areas Tory councillors and MPs are among those kicking off about it. One Essex Tory has warned that:
“as we come out of covid, we have an intense backlog in cancer and mental health and instead of talking about how to restart and reboot the system, we are going to spend 18 months having to pull apart the [memorandum of understanding] that took 18 months to sign. I think this is [a] retrograde step.”
In Cheshire, Tory councillors are bitterly complaining at their health commissioners being merged with Merseyside, fearing Liverpool will call the shots.
Meanwhile in Bedford, Luton and Milton Keynes, a pioneer ICS, costly management consultants Carnall Farrar have warned there is anything but harmony between the ‘partners’:
“Senior relationships are poor and there is a lack of trust in the system. Relationships consistently emerge as a barrier and are strained by unclear accountability and authority…”
The improbably-named “Together We’re Better” ICS covering Staffordshire and Stoke on Trent boasts about having eventually secured support from the Local Medical Committees for the CCG merger, having beaten down the strong opposition from GPs in five of the six CCGs: but shadow board papers warn that “priorities will be reflective of the financial challenge across the system”.
In Nottingham and Nottinghamshire ICS, one of the few with serious board meetings and papers, there are also big financial worries about hitting tough targets.
But the biggest nightmare of all is tucked away in the February board papers of the Lancashire and South Cumbria ICS, which reveal the enormous scale of the financial problems lying in wait as the ICS gets ready to operate a single system-wide “pot” of funding. A February 3 update on longer term financial challenges begins with a far from distant mega-gap in funding:
“… all in all the implication of the guidance is that L&SC could be in deficit somewhere within a range of £240m to £340m (depending on how much NR [non-recurrent] money may be made available). The Board may recall that in February 2020 the assessment was of a deficit of £277m which, when taken together with the 23rd December NHSEI letter, leads me to advise that the gap could be at around the £300m mark.” (page 41)
This is equivalent to 8% of the ICS’s £3.7bn budget: to clear it even over a period of time would require far-reaching cuts in provision of services. Even NHS England has recognised that such huge sums cannot be saved straight away, if at all: the “control total” target prior to Covid called for a reduction in the deficit by a staggering £180m, from £277m to £97m.
The report sums up: “A £300m deficit reduced to zero over three years = £100m (2.7%) savings a year and over 5 years = £60m (1.6%) per annum. L&SC has never managed an absolute reduction in the amount spent on health services. These facts illustrate the huge challenge facing our system.”
Perhaps even more ominous are the options being discussed for cost-cutting: “our efficiency lead has been mining various data sources to create a view of potential savings opportunities across CCGs…”
According to the “RightCare” model there are theoretical “opportunities” for reductions in spending on Musculoskeletal (£25m) Circulatory diseases (£24m) Respiratory diseases (£14m) Same day emergency care (£14m) Neurology (£13m) Ambulance conveyances (£13m) and even Trauma and injuries (£10m) – totalling £113m (p43).
According to the “Model Hospital” £154m could be saved from overlapping cuts in spending on Obstetrics and Gynaecology (£27m) Emergency medicine (21m) Cardiology (£16m) General medicine (£12m) Orthopaedic and spinal (£11m) and an obvious larger but lower-profile target of non-clinical services (‘back office, estates, etc.’) (£67m).
Even if they could make half the £300m savings target from these, it would still leave another £150m in painful cuts to come. This is the grim new world of ICS financial discipline.
Let’s remember Lancashire and South Cumbria was the ICS where the director of finance and investment openly stated back in 2019 that he wanted the ICS in place so he could push through “tricky” decisions: “The place we need to get to is where we can enforce decisions on a majority basis.”
* The next Lowdown will examine the latest round of new hospital and reconfiguration projects, including the debates over new hospital or hospitals in Lancashire and South Cumbria, Gloucestershire, Leicestershire, East Kent and Sunderland.
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