Reorganising the NHS (again) a failure of ambition, understanding and imagination?

Here we go again. NHS England are now in the final stages of reorganising the NHS along the lines that they flagged up in the 5 year forward view some 4 years ago. The report Integrating Care – Next steps to building strong and effective integrated care systems across England offers two options:

Either – make the current sub regional ICS partnerships statutory with a single CCG in each sub region

OR

Get rid of CCGs entirely and make the Integrated Care System a statutory organisation responsible for managing the allocation of funding at place (local authority level)

The second option is the one NHSEI want.

As usual the solution the NHS takes to wider societal and policy problems is to ……reorganise.

I am not going to spend the rest of of this blog complaining about the decision. I want to focus on the deficit at the centre of these proposals. During the pandemic one of the most important lessons that emerged is the primacy of place. This report recognises this – it talks a lot about ‘subsidiarity’, primacy of ‘place’ and ‘neighbourhood’. 

However, the report does not appear to understand why this is important. It is locked into a simplistic and old fashioned view that the NHS is a bundle of services that are packaged up to be delivered at local authority, neighbourhood and subregion – it assumes that the challenge is one of technical delivery – rather than a negotiated relationship with all local stakeholders including the public.

No understanding is shown as to why local accountability, scrutiny or co-production is essential.

The reality is and should be that places have to make the tough decisions which requires local accountability. For example, in Sheffield there was an extensive consultation by the CCG on reorganisation of the Urgent Care system – which mobilised many groups in the city – mainly in opposition. This included regular lobbying of the CCG Governing Body. This pressure lasted for months – and was a constant reminder and challenge to the CCG that its analysis of the problem, the actions it was proposing and the way it communicated them was not good enough. At the end of this process this accountability and engagement ensured that the CCG listened and took a more thoughtful approach with regard to this agenda.

I am not convinced that the NHSE model – creating provider partnerships at place level provides the relationships, the longevity or the accountability that a corporate body with a board discussing difficult issues in public does. 

Partnerships are not an effective mechanism for public accountability.

We only have to look at the current ICS model (where accountability rests with each member) to see how hard it is for the public to engage and influence Integrated Care Systems and Sustainability and Transformation Partnerships, yet this seems to be the model proposed for partnerships at place level.

What can we do?

• First, in order to make better decisions local NHS provider organisations must create a budget to fund a local independent function that will test and challenge local health and care decisions. This will be crucial – not least by providing resources to citizens who will want to engage with local decisions and with those of their ICS. This independent function could sit in local Healthwatch, Local Government scrutiny services or even with an academic institution.

• Second, provider organisations at a local level need to invest in a collective approach to building citizen voice to ensure that the way in which patient and public experience of health services is heard is significantly strengthened. This must include investing in VCS organisations who work with communities of geography and interest particularly those who are easily ignored.

• Third, we need an honest assessment of how Primary Care Networks are going to connect with communities. Mechanisms such as Patient Participation Groups have had very little impact – if PCNs are to be the point of connection with communities we need to be clear about how much of this local relationship building can actually be done by Primary Care Networks.

• Fourth we need to build robust strategic structures embedded in local authorities where membership includes councillors, supported by senior officers, NHS leaders and public voice membership (lay members). These need to control significant proportions of NHS and local government spend – for example in Sheffield the Joint Commissioning Committee is in charge of the £.5bn Better Care Fund allocation.

We will need to build these mechanisms not only to make better decisions locally but also to ensure that a stronger place based voice is heard in public at ICS level.

What do you think?