An update on changes in the NHS

Posted on 05/02/2021 by Ed Hammond.

With the effects of the pandemic still acute, it’s easy to forget that the NHS is in the middle of a change programme. For the last few years NHS England has been putting efforts into the design of healthcare using a larger footprint – originally framed around sustainability and transformation plans (STP) and now integrated care systems (ICS).

This post explains a little more of where we are in that process and what you can expect in the coming months.

First, a reminder of what ICS actually is. The NHS in England is shifting to an approach where decision-making happens at three levels –

• the neighbourhood, focused on “primary care networks” (PCNs), grouping together GP practices;
• the place, focused for the moment on clinical commissioning groups (CCGs), usually coterminous with a local authority and for the past 15 years or so the “default” geography for much local decision-making;
• the system, focused on integrated care systems (ICSs). At the moment ICSs are an informal bringing together of health services partners and others to support strategic decision-making.

The use of the word “system” is meaningful – it involves an acknowledgment that the NHS, and individual NHS bodies, are part of a wider local landscape around health and care. Local authorities are key partners in this system, as are a range of other organisations.

There are a fairly large number of vanguard areas moving forward with ICSs. Having started with four, the number of areas taking active steps down this road is well into the double figures. In due course, most people in England will be covered by an ICS.

Of course serious action has been placed on something of a hiatus in the last year. But change is restarting, and accelerating. A few key changes are coming down the tracks:

• The debate on whether ICSs will stay as more light touch confederations of existing organisations, or whether they will become more formalised legal bodies. If the latter, it seems possible or likely that some existing trusts – and, very likely, CCGs, will be “folded in” to them. This may lead to the beginning of the end of CCGs less than a decade after they came into existence – and an end to coterminosity;
• The debate on community involvement. It is expected that the move to ICS will lead to a step change in how the NHS engages with and involves local people. The “system” ethos is about collaboration and partnership. It will be instructive to see how this comes to be embedded;
• For further change to happen we can expect legislation. We’ve been advised that this may emerge in draft form as early as May. This may mean that this month (February) the NHS surfaces concrete plans on some of these issues and begins to invite views before business in Parliament begins. Of course, all of this is highly likely to be impacted by the pandemic.

What might all this mean for scrutiny? With more decision-making happening at ICS level we may see more joint committees. ICS is all about transformation of acute and community health services so we can expect that plans will involve substantial variations which may cover a large footprint. All this will put pressure on scrutineers. It will also place demands on NHS colleagues, who will need to understand the prevailing rules and expectations around scrutiny’s engagement. We know that awareness of these issues amongst NHS staff is not universally excellent, and we’re working hard with NHS England and NHS Improvement to think about what we can do to raise awareness.

We’re not aware of any plans to substantive alter scrutiny’s powers, but a refocus on community involvement does have the potential to place scrutiny at the heart of future change arrangements. Councillors can play a valuable bridging role between local communities and the NHS. We know that health scrutiny can – through tough and visible action – successfully influence NHS partners to change their plans for the better.

Relationships between scrutiny and the NHS in many parts of the country is very positive – but, once again, we have to prepare for the shifts in staff and the loss in organisational memory that tends to accompany these big changes. What can you do now to act on this?

• When plans emerge nationally, speak informally to NHS colleagues about their expectations of what this means locally;
• As far as possible, sketch out mutual expectations for what scrutiny’s ongoing work might look like during the transition period and once new arrangements are in place;
• Think about how scrutiny will engage with new partners – with ICSs themselves, with PCNs – and how scrutiny will continue to engage with existing partners like Healthwatch and acute and specialist trusts.

We are watching things keenly as they develop, and as February continues we will hopefully be in a position to update with more detail.