Could we be in the last days of relative transparency and local accountability in England’s NHS. It has seemed profoundly unsatisfactory up to now, but if ministers get their way we will soon see how much worse it can get.

It’s all set to change with the imposition right across the country of so-called “integrated care systems” (ICSs) – to be followed up by new legislation that will establish them on a statutory basis. The government proposals for this legislation, outlined in the recent White Paper, would also scrap the remaining Clinical Commissioning Groups (CCGs), but also abolish some of the key powers of local authorities (dating back to the 1970s) to hold NHS bosses to account and challenge controversial hospital closures and reconfigurations.

These changes will make it harder than ever for health workers or the local public to find out what’s going on at local level, and for local communities to challenge or lobby for changes from ever-more remote NHS management.

From April 1 many if not all of the remaining 100-plus as-yet unmerged CCGs will be merged to form the basis of just 42 Integrated Care Systems.

In Cheshire this means that the county-wide CCG, only established last April, will be scrapped after a year of inconclusive life, and merged with Merseyside – despite the opposition of the county’s Tory councillors who fear it will fall under the thumb of the Liverpool City Region.

The transition from CCG to ICS is not just a question of much less locally based bodies taking decisions and reduced local accountability: CCGs (after an uncertain start in 2013) have operated as public bodies, with their governing body meetings held in public and most of their board papers published and they are subject to the Freedom of Information Act.

This of course has not stopped CCGs doing outrageous things, energetically complying with the 2012 Health and Social Care Act that requires them to put a growing range of services out to competitive tender, eagerly handing out contracts to dodgy private companies, spending millions paying management consultants to draw up savage plans for “centralisation” and reorganisation of hospital services, drawing up growing lists of services no longer available on the NHS, and blanking local politicians and communities seeking to challenge them.

However, as they stand most of the ICSs that are to replace them are not, and do not aspire to be, public bodies, or accountable other than upwards to NHS England and the Health Secretary, who would gain new powers to intervene and to veto appointments of top management under the government’s proposals.

Most of them have little or no public profile or activity, and little more than neglected, often purely superficial websites. Local communities that do not know what NHS leaders are discussing or planning and have no responsible body they can lobby to have their problems addressed are disempowered communities – and all the talk in the world about “engagement” will not alter this.

The Lowdown has been periodically checking for any signs of genuine life in the first rounds of ICSs to be approved by NHS England – but in most areas we have found little or none. Our latest survey in March 2021 shows little if any change.

Of the first 29 ICSs, over two thirds (20) still give no public information about Board meetings or publish any papers. Many have still published nothing of note since the Sustainability and Transformation Plans (STPs) of 2016.

Of the 13 STP areas in which unmerged CCGs will be merged and shadow ICSs launch in a few days time, more than three quarters (10) also lack any evidence of the establishment or plans for an ICS Board to meet in public, and have published no plans or papers indicating how they intend to proceed. Herefordshire & Worcestershire, for example boasts a “charter” on integrated care that promises:

“We will work together at pace to challenge ourselves and each other to deliver our aims. We expect to make real progress in 2018.”

Of course the Covid pandemic has clearly diverted attention away from ‘transformation’ and reorganisation of services: Kent & Medway for example, where the merged CCG in January ranked preparation for an ICS as only its FIFTH priority, noted on its website that:

“As the majority of our workforce is supporting the NHS in Kent & Medway’s response to Covid-19, transformational work led by the Kent and Medway STP is on hold. During this time, we will not be updating this website.

However the work being “on hold” has not stopped Kent & Medway pressing ahead for ICS status this month.

Of course the logical response to the restricted scope for discussion and reorganisation during the pandemic would be to at least postpone the far-reaching changes that threaten for a second time in a decade to abolish the existing local structures running the NHS.

Instead up and down the country the same old trite formulae are trotted out, or nothing at all is said; either way the public and health staff are left in the dark as the deadline for CCG mergers and ICS formation looms closer.

Cambridgeshire and Peterborough might appear to be an exception, with their bold declaration that “Although the STP Board is not a statutory NHS body we want to ensure openness and accountability to the public in the business of the Board and, therefore, our meetings will operate in a similar manner to Statutory NHS body Boards.”

However the emptiness of this is revealed in the decision last November that “To support the creation of the ICS, a consistent and compelling approach to communications and engagement is required.” The Board agreed five “key communications priorities for the next six months,” including  production of an ICS website “in partnership with CUHFT (whose web platform we plan to utilise to maximise return on investment and minimise costs)” and a monthly newsletter.

A “Band 7 individual” was to be recruited “on a temporary basis for six months” to help support the production of materials/ content, “working under the guidance and management of the Head of Communications and Marketing at the CCG and System Governance/Business Manager.”

None of this appears to have happened. There is no website.

Whatever is being done to prepare or advance the work of ICSs is being done behind firmly closed doors and with no public information or scrutiny.

Nor is there any real integration. Despite all the warm words, local government remains firmly on the fringes of decision making even if they are involved at all – and the proposed legislation to give ICSs statutory powers would also strip away existing powers from elected local politicians.

As a consolation prize the White Paper offers councillors the prospect of running subordinate “Partnership Boards” that would be open to all and sundry – including private companies – although what influence they may have is open to doubt.

As we have warned, the ICSs are not really integrated, they don’t care, and it’s clear many are not even systems: the one definite change they bring is far less accountability to local communities – and more to Matt Hancock.

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