Matt Hancock’s resignation and replacement by austerity man and neoliberal Sajid Javid could well result in further delays to the government’s Health and Care Bill giving statutory powers to Integrated Care Systems (ICSs). Although no date had been announced for publication of the Bill, it had been expected that the first and second readings would take place prior to the summer recess on July 22.

But even with NHS England primed and cocked ready for the new legislation to take effect next April, it’s not at all clear whether Javid will want to walk straight in to the battles that were lining up over aspects of the Bill that Hancock had specifically added to the NHS England proposals, giving him new powers. 

Tensions and questions over the wisdom of the Bill had been growing within the Tory Party. Analysis for i-news by Spectator assistant editor Isabel Hardman, written before news broke of Hancock’s affair with Gina Coladangelo, suggested he had lost the confidence of back benchers and ministerial colleagues, and that following Prime Minister Johnson’s famous leaked description of him as “f****** hopeless”:

“I understand from multiple sources that Number 10 is not fully on board with the reforms as they currently stand.”

More evidence of Johnson’s lack of confidence in Hancock could be seen in the continued expansion of a separate Downing Street “delivery unit” to “oversee” the recovery of the NHS after the pandemic, and “intervene where delivery is slowing”. The HSJ has highlighted the advertisement for a deputy director to join the growing team based in the Cabinet Office, which already includes former NHS hospital and Centene boss Samantha Jones and former McKinsey man and NHS Improvement director Adrian Masters.

Hardman points out that 20 percent of the Bill is “politically driven” and had been inserted by Hancock over and above the changes requested by NHS England.

On at least one of these additional points Hancock had already had to retreat, with the HSJ reporting that the Bill would not axe the Independent Reconfiguration Panel, as proposed in the White Paper. It would be logical for this retreat also to extend to dropping plans to end the right of local authorities to block controversial reconfigurations and closures and refer plans to the Secretary of State – although it was not clear whether this White Paper proposal would remain in the Bill.

The most contentious elements of the likely Bill include new powers for the Secretary of State to intervene in controversial local reconfigurations, abolish arm’s length bodies and (without restoring the duty of the Secretary of State to provide comprehensive health services, axed by Andrew Lansley’s 2012 Act) give orders to NHS England. 

Hardman reports: “Backbenchers aren’t happy. They already don’t trust Hancock with the powers he has. ‘Do I want the Secretary of State to have even more power? What do you think?’ laughs one, bitterly.”

Contentious issues also include the potentially disruptive requirement, spelled out in February’s White Paper, for ICS boundaries to be coterminous with top-tier local authorities.

This issue also put Hancock at odds with NHS employer bodies, NHS Providers and the NHS Confederation, both of which have (belatedly) cottoned on to the implications of the February proposals, which would require a reorganisation of several ICSs which largely follow the arbitrary boundaries of the ‘Sustainability and Transformation Plans’ established by NHS England five years ago.

Essex for example, replete with Tory councillors and MPs, was divided into THREE STPs – with West Essex hived off to link up with Hertfordshire, and North East Essex tacked on to Suffolk, leaving a core STP covering Mid and South Essex. This division followed on the exclusion of West Essex and NE Essex from the “success regime” set up in 2015 to address chronic failures of leadership in Essex – ignoring loud protests from local councillors at the time.

Now Essex County Council’s new Tory leader Kevin Bentley has revived the call for a single county Essex ICS, in line with Hancock’s White Paper, but in opposition to local and national NHS bosses, with NHS Providers boss Chris Hopson arguing that boundary rows could “worsen patient care”.

Other ICS areas facing potential boundary rows involving local Tory politicians include Frimley (spanning parts of Surrey, Berkshire and Hampshire), Birmingham (divided into two ICSs) South Yorkshire and Bassetlaw, Derbyshire, and Cumbria.

Will Javid simply follow Hancock’s line and walk straight into a series of arguments?

There are other concerns about the plans. The NHS Confederation’s spokesperson on ICSs Dame Gill Morgan has warned that the proposals could bog down NHS bosses in interminable meetings, telling the HSJ:

“… particularly if you’re in a big ICS, that could be an absolute panoply of meetings and subcommittees, all of which are valuable in governance terms but in delivering the vision of partners … to deliver long term health [solutions] it could be a bureaucratic nightmare.”

To make matters worse, it’s clear that many of the meetings required by the new system would be largely tokenistic and pointless.  This is illustrated by recent decisions in Greater Manchester, where it appears that one of the largest ICSs is set to ignore the niceties of “place” (borough) level structures and allocate the lion’s share of the budget for acute care to the “provider collaborative” of large acute trusts with a combined budget of £4.8 billion. 

Only the much more limited stream of funding for primary and community services would be devolved to borough-level boards.

In other words this vindicates the warnings of campaigners that the forced merger of Clinical Commissioning Groups and the carving of England’s NHS into just 42 ICSs would end any local accountability. The Greater Manchester version of “integration” of health care completely removes any local voice or control, and drags the NHS back to the old days when the large acute hospitals – now banded together in an even more powerful block – called all the shots. 

Meanwhile new guidance from NHS England on the design framework for ICSs  helps identify issues on which campaigners and opposition MPs might usefully focus and propose amendments to the Bill to draw the teeth of the new bodies.

Minimal, vague reference to the role of the private (“independent”) sector is coupled with repeated vague references to “other partners” to be involved in decision making committees – at a time when we know Virgin has already been given a seat on the board of the Bath Swindon and Wiltshire ICS. The Bill must be amended to specifically exclude any involvement in any decision-making ICS bodies of companies providing clinical, support services, data services or consultancy to the NHS: they should be referred to as contractors rather than misleadingly termed “partners”.

Numerous references in the White Paper and ICS websites to creating an “agile” and “flexible” workforce across ICS areas underline the need – especially at a time of chronic staff shortages and rock-bottom post-Covid morale – for ICSs to be required to comply with nationally-agreed pay, terms and conditions, and negotiate terms for any local “flexibility” with the trade unions.

The ICS NHS body is required to include a member “drawn from general practice providers”: this vague phrase could include a representative of Centene or other commercial companies holding GP contracts. The Bill must be amended to exclude all but GPs employed on the main NHS (GPMS) contract. And in line with the professed aim of “integrating” primary care and other NHS services, ICSs as commissioners of GP services  should be banned from issuing any more of the APMS contracts through which Centene and similar corporations gained their foothold in primary care.

The new guidance weakly “invites systems to consider” agreeing arrangements for transparency and local accountability “including meeting in public with minutes and papers available online”: the Bill clearly needs to be amended to require ICSs to operate this way, but also to require that all ICS business and contracts must be discussed in public with none of it deemed commercial or confidential.

The Lowdown will offer a more detailed critique of the Bill, its implications, and more extensive suggestions on how its damaging proposals can best be combated as soon as it is published. But don’t hold your breath waiting!

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