Key points

  • The new reorganization of the NHS will lead to a loss of accountability according to the Local Govt Association
  • The integration project is not fully joining health, well-being, and social care systems
  • GPs and the mental sector worry that they will be overshadowed by powerful acute trusts

NHS England/Improvement (NHSEI) has just concluded a perfunctory consultation on the details of new legislation which they want the government to enact early this year. They hope to give legal legitimacy to changes that are already well advanced, establishing Integrated Care Systems (ICSs).

This has required a process of merging (and eventually abolishing) CCGs, which were established as public bodies by the Health & Social Care Act 2012.

The consultation was unreported by mainstream media and largely eclipsed by the Covid crisis, so the implications of the proposed changes for local accountability, availability, and access to services are not widely understood by the public or NHS staff.

However the final few weeks of the consultation have seen increasing expressions of doubt over key aspects of NHSEI’s plans, perhaps most conspicuously and surprisingly from the Local Government Association (LGA), a normally conservative all-party body that represents the leaders of 335 of England’s 339 local authorities. Their response states:

“We are concerned that the changes may result in a delegation of functions within a tight framework determined at the national level, where ICSs effectively bypass or replace existing accountable, place-based partnerships for health and wellbeing….

“Calling this body an integrated care system is to us a misnomer because it is primarily an NHS body, integrating the local NHS, not the whole health, wellbeing and social care system.”

The loss of local (“place based”) accountability is the inevitable result of slashing the number of commissioning organisations (Clinical Commissioning Groups – CCGs) from almost 200 to leave just 42 new “Integrated Care Systems” (ICSs) covering England.

The LGA criticism reinforces widespread suspicion of the extent to which ICSs, which have been set up and function largely in secret, would be in any way accountable to local communities if given statutory powers.

The mergers inevitably result in bodies that are more remote from the needs and concerns of any local community. But there are also concerns over how the new bodies will function. The Health Service Journal has pointed out how vague are the proposals:

“… ICSs will be given a “single pot” of money from which to manage spending priorities. But there is no framework for how this will be spent that assures fairness, value for money and quality outcomes.”

Many GPs fear primary care, after a leading role in CCGs, would once more be marginalised in ICSs dominated by large-scale acute hospital trusts.

But NHS Providers, representing trusts and foundation trusts, has also expressed reservations, warning that: “trust leaders – and partners from across the health and care system – are cautious about any top-down, inflexible reorganisation of the NHS, particularly in the middle of a pandemic.”

Even the NHS Confederation, representing public and private sector providers and commissioners, and broadly supportive of most NHSE proposals, appears to be uncertain of the future. Its commissioning wing (NHS Clinical Commissioners) warns:

“The local stewardship role of CCGs and their joint working with local authorities must not be lost – we cannot throw the baby out with the bathwater,” (although it’s not quite clear what the “bathwater” is in this case.)

Their statement continues with a promise that appears far from confident: “We will seek to influence NHSEI at the highest level in order to minimise disruption and destabilisation, consolidate the positive, and that way we can ensure the fantastic legacy of CCGs lives on in ICSs.”

The Confed response admits that “Primary care network leaders were the least supportive of the health and care leaders we surveyed recently about ICSs becoming statutory bodies because of the level of unrest this could create at a local level ….”

And its Mental Health Network expresses the danger that other providers could be “overshadowed by acute sector needs,” and argues that any legislation must ensure an equal footing for mental health –  an issue that are conspicuously not covered in the 39 page NHSEI document “Integrating Care” that sets out the two options for consultation.

There is no sign NHSEI will take note of any of these reservations. They are forging ahead regardless. 29 of the proposed 42 ICSs have already been approved by NHS England – even though they lack any legal status, and almost all operate behind closed doors with no public accountability. The remaining 13 STPs are required to become ICSs by April, or face the intervention of an “intensive recovery support programme.”

ICSs have been driven from the top by NHS England, and in many areas resisted at local level by councils, GPs and campaigners. However “Integrating Care”  claims they are “a bottom-up response,” and that the handful of early ICSs “have improved health,” and “developed better and more seamless services.”  In fact as The Lowdown has reported,  the improvements that have been made along these lines have been made under existing legislation.

There are also repeated references to using “digital” and “data” as ways of driving system working and improving outcomes. But while there has been increased use of telephone and ‘virtual’ consultations during the Covid pandemic, many vulnerable people are among the millions digitally excluded. NHSE ignores this major weakness of “digital first” approaches.

Digital technology and number-crunching are among the more lucrative areas in which private companies are seeking profitable NHS contracts, not least through the Health Systems Support Framework established by NHS England to facilitate easy contracting by ICSs.

 

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