In 2018, we recommended that the law needed to change to fully realise the move to a more integrated, collaborative and place-based approach to health and care. We were pleased that the Prime Minister acknowledged this and then asked NHS England and NHS Improvement to make proposals for legislative change.
The current legislation was designed to encourage choice and competition in the NHS, rather than collaboration. Since the NHS Five Year Forward View, the NHS has had to use workarounds to overcome barriers posed by the legislation. To avoid the mistakes of previous reforms, we recommended that the health and social care community should lead the development of proposals for legislative change.
NHS England and NHS Improvement’s proposals are broadly welcome. They are a pragmatic set of reforms, which remove barriers to integrated care. This evolutionary and consultative approach to health reform is welcome, particularly given the challenge of legislating in a hung Parliament and the fact that there remains little appetite for another large-scale top-down reorganisation of the NHS.
The proposals, we heard, are nevertheless too NHS-centric, with too little consideration for the wider system with which the NHS seeks to integrate. The Department of Health and Social Care, NHS England and NHS Improvement should be clearer about the input and roles local government, the voluntary and wider community sector, as well as independent providers, are expected to have in the future of the NHS.
We warmly welcome the intention behind the proposals to promote collaboration and lessen the role of competition in the NHS, especially the proposal to repeal section 75 of the Health and Social Care Act 2012 and revoke the regulations made under it. Competition rules add costs and complexities, without corresponding benefits for patients and taxpayers in return. Choice and competition can help raise standards and encourage innovation, but, as an organising principle, collaboration is a better way to manage the rising demands on health and social care, improve joined up care for patients and deliver better value for taxpayers. This does not mean however that the NHS should become a monopoly.
The Department of Health and Social Care, NHS England, NHS Improvement and the NHS Assembly should co-produce a ‘best value’ test, underpinned by a broad definition of value. The quality of care and health outcomes should be at its heart, but it should also be aligned with the underlying concepts of wider public and social value used by other public services. The term ‘best value’ itself is perceived in local government to be synonymous with cost-cutting, so we recommend it should be replaced because it is the principle that is most important.
The law should rule out the prospect of non-statutory providers holding an Integrated Care Provider contract. Until the law is changed, we strongly urge that any ICP contract should be held by an NHS body.
We support the proposal to give the Secretary of State powers to create new NHS trusts. This will help commissioners who struggle to find a suitable provider to hold an ICP contract. The decision to create a new NHS trust must have local buy-in and represent the most effective use of local resources. This power must not be used by the Department or national bodies to impose a form of integration on local health and care services or as threat to force organisations to collaborate.
Now is not the right time to establish integrated care systems as separate legal entities because that would require far more extensive legal changes. However, we are concerned about the governance and accountability of ICSs. All STPs and ICSs should meet the highest standards of openness and transparency in the conduct of their affairs by holding meetings in public and publishing board papers and minutes. Transparency is not as good as formal accountability, but to avoid another top-down reorganisation of the NHS, we believe it is the most pragmatic way forward.
Proposals to improve system working, such as the formation of joint committees are too NHS-centric. The law should enable local authorities to participate in joint committees with providers and clinical commissioning groups. The proposed “triple aim” of better health for everyone, better care for all patients and efficient use of NHS resources should be rephrased to include a specific reference to wellbeing.
More detail is needed on how giving the Secretary of State powers to transfer, or require the delegation of, functions from one arm’s-length body to another will improve joined up care and value for patients. The strategic intent behind this proposal is unclear.
The NHS at a national level must continue to support, encourage and empower local leadership. We do not support the proposals, in their current form, to give NHS Improvement the ability to direct foundation trust mergers, acquisitions and capital spending limits. While we support, in principle, the proposal for NHS England and NHS Improvement to merge, we are concerned about the degree of central control that could result from this merger, especially in light of the other changes put forward. We would like to see more detail on how unintended consequences of this merger will be avoided.
When these proposals come before us again as a draft bill, one of the issues we will want to consider very carefully is how local autonomy will be protected under the new arrangements.
Published: 24 June 2019