32.At the heart of the Government’s reform of health and social care is the proposal to place Integrated Care Systems (ICSs) on a statutory footing with a “broad duty to collaborate”, and a “triple aim duty” to pursue:
33.Every part of England will be covered by an ICS that will bring together NHS organisations, local government and wider partners at a system level. The ICS will comprise:
34.The ICS NHS Body will also merge the functions of non-statutory STPs/ICSs with the functions of a CCG. Flexibility will be a key part of the proposals to ensure that ICSs can develop their own processes, structures and decision-making procedures.
35.Placing ICSs on a statutory footing, and assigning them clear duties will, the Department states, deliver more efficient and more collaborative health and social care services to local populations. The Health Foundation, however, noted while legislation is necessary, “making collaboration work depends as much on culture, management, resources, and other factors as it does on NHS rules and structures”. The King’s Fund agreed, noting that the success of the reforms would be “critically dependent on culture and behavioural change” rather than on legislation.
36.Our witnesses and those organisations that submitted written evidence were broadly supportive of the establishment of statutory ICS NHS bodies and Health and Care Partnerships. However, for many, the success of the new bodies would be dependent on the Bill setting out in detail how they would work together, their powers and the composition of their boards.
37.As our witnesses highlighted to us, the quality of the relationship between the NHS ICS Body and the Health and Care Partnership was central to the overall effectiveness and success of the new ICSs. The Nuffield Trust highlighted the potential risk that ICSs could become NHS focused to the detriment of wider collaboration and that the dominance of an NHS Trust in terms of size and funding could “unbalance priorities and create unintended conflicts of interest, especially when they take on the responsibilities of CCGs for selecting providers and giving out money”. This concern was also raised by the Kings Fund who believed that there was a risk that ICS Health and Care Partnerships may lack the powers to drive change and that the ICS NHS Body could be “too narrowly focused on the NHS at the expense of other partners”.
38.The King’s Fund also identified a risk that ICS bodies may “inadvertently drag attention away from the more local ‘place’ level where collaboration can be most fruitful” and emphasised the importance of ICSs “building up from ‘places’.” It believed that the Government needed to provide greater clarity on how the plans of the ICS NHS Body and the ICS Health and Care Partnership; and joint health and wellbeing strategies from Health and Wellbeing Boards at the more local place level will be aligned to ensure that there is no duplication or overlap.
39.NHS Providers said that while they understood the rationale behind the proposed two-part statutory model for ICSs, there was an enduring concern about “the distinct probability of unclear and duplicate accountabilities between the various bodies already in existence”. For that reason, it argued for greater detail on how “the different bodies, their roles and accountabilities fit together without duplication or overlap”.
40.In its written submission, the Policy Research Unit in Health and Care Systems and Commissioning emphasised the need for further detail and guidance in relation to decision-making, governance and accountability structures; and the mechanisms that will be put in place to avoid conflicts of interest. The Chartered Institute of Physiotherapy was also concerned that the NHS ICS Body had the potential to become too narrowly focused on the NHS if the ICS Health and Care Partnership lacked the necessary powers to drive change. The Royal College of General Practitioners also noted this risk where the organisational culture within an ICS was not well established, or where the interests and accountabilities of large and powerful organisations could overtake the aims of the wider system.
41.The Royal College of Physicians noted the varying level of development of ICSs across England and that it would be important that both support and guidance was provided to “fledgling” new bodies to enable them to “learn from those that are more established and more experienced”. It also wanted to see greater clarity on the relationship between the two new bodies to ensure that all stakeholders are meaningfully involved and that voices outside the NHS are heard.
42.In relation to guidance, the Local Government Association stressed the importance of it being produced as a partnership between central and local government and sought “a commitment on the parliamentary record” to that effect. It further argued that any future accountability mechanisms built on and enhanced existing local democratic accountability and that “local government needs to remain directly accountable to our residents”.
43.Sir Simon Stevens acknowledged the need to ensure accountability and the importance of providing guidance and support. However, he cautioned against over-prescription in this regard, in favour of “a permissive framework that enables sensible local judgments to be made.” Amanda Pritchard said that the benefits of the proposals were to enable ICSs to “understand the local needs of your population, and design services that bring together primary care, community, acute, mental health, and partners, to best meet the needs of the population”. As examples she cited the ability to:
44.Amanda Pritchard also said that ICSs would also build on the co-terminosity seen in the last year and the “strength of the relationship between local government and the NHS”. She added that the proposals in the White Paper should deliver a “permissive framework, with a set of principles that then guide local decision making” which would give stakeholders “the space locally to make sure that they have an outcome […] that really works for the local population and for the local situation”.
45.The success of ICSs will, in no small part, be dependent on good working relations between the NHS Body and Health and Care Partnership. While we agree with Sir Simon Stevens that the proposals provide flexibility for local decision-making, clear lines of accountability will be necessary to ensure that both component parts of an ICS can function efficiently and effectively.
46.We therefore recommend that the Government include in the Bill a more detailed framework that sets out the roles and responsibilities of both the NHS Body and the Health and Care Partnership and of the Chair of the ICS. NHS England should set out in guidance how the responsibilities and accountabilities of NHS trusts and foundation trusts align with these to avoid confusion, duplication or overlap.
47.The Health and Care Bill provides the Government with an opportunity to reform the procedures for appointing individuals to NHS boards. In relation to the new NHS Body and the Health and Care Partnership Body, Sir Simon Stevens agreed that it would be important to provide guidance on the appointment of board members but cautioned that such guidance should not be “too prescriptive” because there were a “different set of arrangements, challenges and partners in different parts of the country”. Amanda Pritchard agreed, stating that guidance was “the absolute minimum that you would expect to see around the governance table” and that it would set a “minimum expectation” for the governance of boards.
48.In addition, we tested the need to introduce a reformed fit-and-proper person test for the appointment process. Sir Simon agreed that the Bill presented an opportunity to introduce a reformed UK-wide fit and proper person register for appointments to ICS boards. Amanda Pritchard argued that “appropriate and adequate mechanisms” were required where “things have gone very wrong”.
49.When we discussed this with the Secretary of State, he confirmed that he was “open” to the suggestion that the Bill could include reform of the fit-and-proper-persons test for people appointed to the ICS boards. Jason Yiannikkou, Director of NHS Legislation Programme at Department of Health and Social Care, explained that the Department would be bringing forward an enabling power that would “facilitate options in this space”, but cautioned that the Department needed to “wait for the work to be taken forward”. In addition, the Secretary of State explained that the Bill would also provide him with a power of veto for board Members meaning that they would be joint appointments between the Secretary of State and the NHS.
50.Other witnesses highlighted the importance of clarity in relation to the composition of boards. Carers UK believed there should be “clear and explicit references to carers” in any duty for the new bodies to consult with patients and communities, and that there should be a carer representative on the key decision-making bodies. Healthwatch also were in favour of a wide range of representation on boards. While it welcomed the White Paper’s explicit reference to involvement of Healthwatch in the new systems, it set out how it believed that involvement should work. Healthwatch argued that the Bill need to clearly set out a non-voting, independent role for Healthwatch on the ICS governance boards.
51.The King’s Fund noted that the White Paper did not contain detail on “precisely who will be on the boards”. In a similar vein, there is little detail on the appointment process in relation to the boards. When we questioned the Secretary of State, he explained that the proposed approach on appointments was that “NHSE would make appointments, but they would need to be signed off by the Secretary of State” and that this was “effectively moving appointments to joint appointments”. The Secretary of State also confirmed that his office would have “a power of veto” for chairs of boards. A number of our witnesses raised concerns about the potential politicisation of the NHS as a result of the proposed powers to be given to the Secretary of State and the power to appoint and veto raises similar concerns.
52.It is vital that local populations have confidence in the boards of the NHS Body and the Health and Care Partnership and transparency in the appointment process for those boards will be a key factor in that. If NHS Bodies and Health and Care Partnerships are to be successful they must not be dominated by the views of the NHS but draw on the experience and expertise in all areas of the health and care sectors as equal partners. We therefore recommend that a duty be placed on ICS boards to ensure that:
b)where an ICS’s decision-making affects carers and the social care sector, that the ICS undertake formal consultation with the groups and sectors affected.
53.The White Paper will give the Secretary of State the ultimate responsibility for appointments to NHS boards. Given the concerns about the potential politicisation of the NHS, there will need to be full transparency in the appointment process. We therefore recommend that the Bill sets out the criteria by which the Secretary of State will use this power so that appointments and vetoes decided upon can be assessed.
54.We conclude that the Bill provides a timely vehicle to introduce reforms to the fit-and-proper persons test for appointments to NHS boards. We therefore recommend that the Bill is used to establish a UK-wide public register of people that are holding, have held, or are seeking to hold a position on an NHS board. We also recommend that NHS England and the Department undertake a review of the adequacy of the training and support provided to board members.
52 , para 3.11
53 , Page 3.8
54 , para 5.7
55 , Page 19
56 , Page 31, para 5.8
57 , Page 32, para 5.9
58 Health Foundation ()
59 King’s Fund ()
60 Nuffield Trust ()
61 King’s Fund ()
62 King’s Fund ()
63 King’s Fund ()
64 NHS Providers ()
65 NHS Providers ()
66 The Policy Research Unit in Health and Care Systems and Commissioning ()
67 The Chartered Society of Physiotherapy ()
68 The Royal College of General Practitioners ()
69 The Royal College of Physicians ()
70 The Royal College of Physicians ()
71 Local Government Association ()
72 Local Government Association ()
85 Carers UK ()
86 Carers UK ()
87 Healthwatch ()