Sustainability and transformation in the NHS Contents

2Partnership working

Accountability arrangements

16.Population and demographic changes increased demand for health services by 1.3% in 2016–17. Therefore, as well as balancing its books each year, the NHS needs to invest in new ways of working that can better serve the changing needs of patients and increasing demand for services. Since 2016, healthcare commissioners, trusts and local authorities have been working closer together in 44 sustainability and transformation partnerships to develop long-term strategic plans and more quickly transform the way services are provided.36

17.NHS England and NHS Improvement are encouraging sustainability and transformation partnerships, or smaller groupings of commissioners, trusts and local authorities, to evolve into integrated care systems. This involves commissioners and trusts taking control of the health budget for the entire population in their area and bringing together the services and care that they offer. NHS England and NHS Improvement have identified ten sustainability and transformation partners across the country to trial this new approach. This will cover a total of 10 million people and all are expecting to be operational from 2018–19.37 NHS England told us that this new approach will not affect every patient within the local area covered by the integrated care system. However, it told us that those patients with the greatest need for NHS services will benefit from greater teamwork between health and care staff, less repetition of information, and a lower likelihood of going to hospital for a preventable condition.38 NHS Improvement told us that that other parts of the country are enthusiastic to form integrated care systems themselves, and that it is inviting the next phase of potential systems to be involved.39 NHS England and NHS Improvement are aiming to review expressions of interest by March 2018.40

18.In developing the new integrated care systems, the Department said it was not planning to change the law or the statutory basis of organisations and their accountabilities. These will remain as they are currently set out in existing legislation. Instead, the Department told us that it was focusing on how organisations work together.41 We were concerned how accountability would work under these new arrangements. For example, we asked NHS England how, under new integrated care arrangements, patients would complain or comment about the services they receive. NHS England told us that patients’ rights to complain to individual organisations about the different services they receive would not be affected. We were sceptical about NHS England’s hope that it will get to a point where there is a ‘one-stop shop’, with complaints being dealt with across all the organisations involved in a patient’s care.42

Regulation of the healthcare system

19.NHS England regulates the performance of clinical commissioning groups while NHS Improvement regulates the performance of trusts. The Department accepted that because of the large scale of the NHS it is very difficult for these two regulators to give single, consistent messages to the healthcare system. The National Audit Office found that NHS England and NHS Improvement have given sustainability and transformation partnerships mixed messages about the balance between achieving financial sustainability across the healthcare system as a whole and protecting the financial position of individual organisations. For example, NHS England gave commissioners a clear steer to explore payment systems other than payment by results to help manage demand, while NHS Improvement encouraged trusts to use payment by results to maximise the amount of income they received from commissioners.43

20.NHS England told us that at the end of March, it and NHS Improvement will be setting out their plans to work in more joined-up ways both regionally and nationally.44 In particular, NHS England and NHS Improvement said that they were looking at how they can work better together to support commissioners and providers to collaborate and integrate their services. They have agreed shared financial targets for the ten integrated care systems, which means that organisations within the same system will be able to adjust their financial targets to reflect relative pressures and performance, as long as they meet their overall financial target for the system.45 NHS Improvement told us this will create new financial incentives that encourage collaboration rather than competition and allows integrated care systems to respond to new models of patient care. NHS England told us that from 2019–20 it hoped to pay sustainability funding to partnerships and systems rather than individual organisations.46

21.Despite these intentions, integrated care systems are not statutory bodies and not supported by a legislative framework. NHS England and NHS Improvement still hold individual clinical commissioning groups and trusts to account for their individual financial performance. Regulation will therefore default to individual organisations and their legal duties, rather than any wider system-working.47 We received written evidence from the Health Foundation, who told us that NHS England and NHS Improvement need to sharpen their focus on what new national performance and governance frameworks should look like.48

Ensuring the patient voice is heard

22.Sustainability and transformation partnerships are laying the foundations for more strategic system-wide planning and delivery of services for patients. However, the Department told us that the progress made by partnerships in building relationships and delivering their plans has been variable.49 The National Audit Office found that the pace and scale of change of introducing sustainability and transformation partnerships has made consultation with patients and the public difficult. This engagement is key to ensuring patient and service users’ experiences and concerns are heard and addressed. But the different cultures and processes in the NHS and local government meant that partnerships faced a particular challenge in maintaining engagement with local authority partners.50

23.We asked the witnesses to what extent local government and the voluntary sector are being involved and engaged in the work of sustainability and transformation partnerships following suggestions that the voluntary sector in some areas feels excluded. The Department told us that while the role of local government in sustainability and transformation partnerships will always differ across local areas, local government has started playing a bigger role. It told us that its work to join up health and care services through the Better Care Fund and to tackle delays in discharging patients from hospital as examples of where local government and the NHS were working well together, but accepted that further progress needs to be made. On engaging with the voluntary sector, NHS England similarly accepted that locally the level of community engagement in sustainability and transformation partnerships was variable, but that it was taking action at both a national and local level to address this. It told us that it is setting an example for local systems to follow by including charities within its national programmes. For example: the chief executive of Diabetes UK oversees how clinical commissioning groups are assessed on the care and services they provide for patients with diabetes; the chief executive of Cancer Research UK chairs NHS England’s cancer taskforce improvement programme; and the chief executive of Mind leads NHS England’s work on mental health improvement. NHS England recognised that it needs to stimulate and ensure more involvement locally, and has been exploring whether to assess partnerships on the extent to which they involve the voluntary sector.51

36 Q 80; C&AG’s Report, paras 13, 3.2

37 Qq 57, 78; C&AG’s Report, paras 3.2, 3.5

38 Q 99

39 Q 78

40 NHS England and NHS Improvement, Refreshing NHS Plans for 2018/19, 2 February 2018

41 Qq 111–113

42 Qq 120–128

43 Q 108; C&AG’s Report, paras 19, 3.17, 3.20

44 Q 108

45 Q 78; C&AG’s Report, para 3.18

46 Qq 55, 57, 78

47 NHS Providers (STN0008); C&AG’s Report, figure 17

48 Health Foundation (STN0002)

49 Qq 68–69

50 C&AG’s Report, para 3.8 and figure 17

51 Q 117–118

27 March 2018