A major gap in the government’s controversial Health and Care Bill is the lack of any guarantee of much more local “place based” decision-making and planning of services to meet the needs of local communities within much wider “Integrated Care Systems” (ICSs).

The Bill would put just 42 ICSs in control of the NHS across England – several of them covering populations of over 2 million.

The largest, with over 3.2m population, is the most northern ICS (North East and North Cumbria) which will cover from coast to coast – Carlisle to Newcastle, and from Whitby in the south to the Scottish border – an area and population so large and unwieldy that the ICS website manages to avoid displaying a map, listing the 17 councils covered, or any mention of the size of the ICS population.

Four more ICSs have populations of 2 million or more – Greater Manchester, West Yorkshire, Cheshire & Merseyside and North West London.

By contrast 16 of the 42 ICSs have populations of less than 1 million, and three have just 500,000 – Somerset, Cornwall and Shropshire and Telford & Wrekin. But even in the smaller ICSs there are distinct differences between more local “places” within the ICS area.

Putting such large and remote bodies in charge, NHS England has made much of the idea that more local “place-based” arrangements would be able to decide for specific areas and communities.

Indeed even while they were forcing the mergers of Clinical Commissioning Groups into ever fewer local bodies and planning to reduce the number to just 42, the NHS England website has also been singing a different song to avoid complaints of lack of local voice, more or less claiming that ICSs will act as bodies to support place-based ‘partnerships,’ rather than the new decision-makers:

“An important part of our vision is that decisions about how services are arranged should be made as closely as possible to those who use them. For most people their day-to-day health and care needs will be met locally in the town or district where they live or work. Partnership in these ‘places’ is therefore an important building block of integration, often in line with long-established local authority boundaries.

… We are recommending that these place-based partnerships be supported by a statutory NHS ICS body to oversee NHS functions across the whole system….”

A new NHS England guidance document entitled ‘Thriving Places,’ again bigging up the idea that “place-based” decision-making will be part of the new system, admits that:

“We expect the allocation of decision-making functions between system and place will vary across the country and should be shaped through collaborative discussions.”

So there is no guarantee of any real local control: the ICSs will be calling the shots.

However ‘Thriving Places’ goes on to assert that: “The considerations of what is undertaken at system or place should be guided by the principle of subsidiarity, with decisions taken as close to local communities as possible, and at a larger scale where there are demonstrable benefits or where co-ordination across places adds value.” (p21)

This seems to have been enough to convince the Liverpool Health and Wellbeing Board, which has produced its own paper on Establishing Liverpool Health and Care Partnership, noting “the plans to establish a strong place-based health and care partnership – the One Liverpool Partnership” within Cheshire & Merseyside ICS.

This cites recent misleading NHS England guidance documents, and asserts, wrongly that:

“The Health and Care Bill sets out two key components to enable ICSs to deliver their core purpose, including:

  • strong place-based partnerships between the NHS, local councils and voluntary organisations, local residents, people who access services, leading the detailed design and delivery of integrated services within specific localities (Liverpool), incorporating a number of neighbourhoods.
  • provider collaboratives, bringing NHS providers together, working with clinical networks and alliances and other partners, to secure the benefits of working at scale.” (page 74).

In fact neither place-based partnerships nor provider collaboratives are mentioned in the Bill, which makes no reference at all to “place.” Instead it makes clear that each ICS will be able to establish its own constitution – opening up the probability of wide variation in the extent to which ICSs opt to devolve decision-making down to more local level.

There is also the danger that place based partnerships could be used to take the blame for failures to make savings or balance the books at ICS level: Thriving Places states ominously that they “will need to play a major role in the delivery of national expectations attached to NHS funding” (p22).

The Bill as tabled (which may well be substantially amended by the government) would give an additional 138 powers to the Secretary of State – but says nothing about more local structures.

So even if Cheshire & Merseyside does decide to establish the One Liverpool Partnership as a subsidiary body this does not guarantee equivalent arrangements, even elsewhere in Cheshire & Merseyside. Amendments are needed to ensure that the “principle of subsidiarity” is written in to the Bill and that all ICS constitutions are required to spell out clearly how they will devolve decisions to ‘place’ level wherever possible.

Many of the decisions taken on these issues will be steered by the ICS chairs, 25 of whom have already been appointed, with the remainder to be appointed by NHS England in conjunction with the Secretary of State – and can only be removed by the Secretary of State. They will pick up salaries of £55,000-£80,000 for the part-time posts.

With this line of accountability directed only upwards to national level, and not at all downwards to more local place level, the actual level of local control within each ICS will be strictly limited.

Adverts have gone out for applications to become ICS Chief Executives, on salaries from £197,000 to £270,000, incurring predictable ill-informed rage from the Daily Telegraph, which headlined: “NHS spends millions hiring an army of £200,000 bureaucrats.”

The Telegraph quotes ‘senior’ Tory MPs, who had presumably voted in July for the Bill establishing ICSs without realising the new bodies would need to be managed. But while Tories are “appalled” at the new salaries on offer, they appear unaware that with even the smaller ICSs controlling budgets of billions, the CEO salaries on offer are minute compared with private sector equivalents.

Indeed with ICS budgets higher than those controlled by most elected Mayors and much higher than Police and Crime Commissioners, the argument for ICS chairs to be elected, to give some actual control back to the people whose health care is being decided, is a strong one.

While it falls short of long standing demands for health authorities to be elected, it could be pushed forward as an amendment to the Bill that would – for the first time ever – give new power over NHS decisions to people rather than central government and their appointees.


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