Integrated Care Systems – Accountable? Transparent?

The irony of giving people hardly any time to respond to a consultation on transparency and accountability of Integrated Care systems seems to be lost on the Department of Health and Social Care (DHSC) Hewitt Review.

Their consultation was launched on the 13th of December 2022 and closed on the 9th of January 2023. I reckon that is 14 days working days to respond.

I have to say that I am confused because there was a DHSC enquiry in 2022 which covered very similar ground.

Here are extracts from two of the witnesses to that enquiry

Kings Fund

Local Government Association

Problems

Government seems to think that it is essential to restructure the NHS every 5 to 7 years. One of the consequences of this is that most people have little idea of who is making local decisions about what gets funded in the NHS and how to influence them.

Speaking as a former lay member of the Clinical Commissioning Group in Sheffield – There were still many people in Sheffield who had no idea what a CCG was by the time it was abolished. So the new ICS structures will be little understood by most people.

When Integrated Care Boards were established it was clear that their main accountability would be to themselves and to central government

This centralised control and constant reorganisation – can lead to a feeling that the only accountability that ICB leaders really need to worry about is to central government. This is so distant that control tends to end up focussing on activities that can be easily measured such as budget deficit, waiting times and ‘never events’. 

It takes exceptional principled local NHS leaders to give equal weight to complex local challenges that cannot be so easily measured, inequality, lived experience, diverse needs etc.

I think it is really hard for public bodies – particularly the NHS – to admit that there are areas where they are struggling or have made mistakes. This is dangerous. In less than a year we have moved from praising primary care and the NHS to seeing the government and national media attacking them. This has contributed to antagonism from members of the public as they have struggled to access services. 

In my view there is a shameful silence from local health systems – who have not pointed out loudly or clearly enough the demand, financial and quality challenges that are faced by front line staff.

This failure to do so creates a dissonance between what the local NHS is saying and what patients and staff feel they are experiencing.

In my recent blog on health inequalities and how Integrated Care Systems are using or misusing funds to tackle inequalities it was concerning that many readers complimented me on doing what is a comparatively simple piece of work – sending some Freedom of Information Requests and analysing the responses.

What was apparent was that many players in the local health and care system were:

• Not aware of the existence of these funds
• Did not know how to get access to this information
• May have known what was happening but felt unable to challenge or question decisions that had been taken.

This is worrying, not least because it is areas such as health inequalities and public voice that need informed scrutiny and public debate. If they don’t have this they risk continuing to being treated as marginal issues at best.

What can be done?

Here are some thoughts.

A high performing organisation must create mechanisms that challenge what it is doing both internally and externally. That is a key driver for improvement and excellence. Sweeping issues under the carpet will disillusion staff and reduce public trust.

Empower Staff

Organisations such as the Integrated Care Boards need to have internal structures that empower officers who are responsible for engagement, involvement and tackling inequality.

In Sheffield the Clinical Commissioning Group established a separate committee as part of its constitution where all decisions that required public consultation or involvement were sent. This committee considered the approach being taken by the commissioner – for example how were views being sought? Who should be involved? What actions needed to be taken to be inclusive etc. It was not about ‘marking the homework’ it was concerned with empowering the commissioner to make the best decision possible by ensuring that the views of key stakeholders were heard and understood. The Committee membership included public voice members (recruited through open open recruitment) Healthwatch, the local authority and as importantly Directors from the CCG, GP members and members of the involvement, equality and communications teams.

Empathetic learning

Integrated Care Systems need to establish inclusive action learning sets that create a safe and empathetic place for decision makers to honestly share the challenges that they are facing tackling difficult issues and be constructively challenged by peers.

Trusted relationships

There needs to be trusted relationships with different communities and stakeholders.

During the pandemic Sheffield CCG funded at least 20 voluntary organisations who worked with or came from specific communities – learning disabilities, BME communities etc to regularly share their concerns and challenges – with the ‘gold command’ in the city. There was a clear view from decision makers that this assertive relationship building helped Sheffield’s vaccine rollout be one of the best compared to other Core Cities. This approach is similar to the small grant programme run by Healthwatch in Sheffield.

Another great example is how Birley Health Centre have used simple mechanisms such as Facebook to create a platform for the honest sharing of criticism and praise. Most importantly it creates an ongoing relationship with patients at the practice, approximately 10% of patients are members of this group.

Building Capability in communities

Understanding and influencing complex short lived health systems is really hard! In Sheffield there is a long standing Introduction to Community Development and Health course – aimed at citizens from easily ignored Communities. In 2023 this course celebrates its 25th anniversary! Frankly any ICS that is serious about local accountability and transparency should be investing in these sort of local initiatives and taking advice from national organisations such as Citizens UK.

Scrutiny and Challenge

Local Authority health scrutiny committees have an important role here. However, I think that they can be significantly helped by partnerships with organisations who are independent and have the skills and expertise to analyse data quickly. A practical partnership with a university could help here – so long as they understand that they are using their skills to produce fast analysis that helps systems in real time!

Finally – of course there will always be a few old bureaucrats like me with a glass of wine and a computer who will write blogs sharing their opinions – but surely we can do better than that!

WHAT DO YOU THINK?