Fantatstic blog William Greenwood, CEO of Cheshire LMC -Integrated Care System ‘engagement’ document

The new proposed NHS legislation and where this fits in the jigsaw of changes

The 80-page Integrated Care System (ICS) ‘engagement’ document resulted in the White Paper with no real surprises. For some time, the drive has been a move back towards regional control with local implementation; some may argue the Strategic Health Authority wheel has come back round.

The main thrust of the paper is to make ICSs, previously known as STPs (Sustainability & Transformation Partnership) statutory bodies as the foundation for the newest NHS reforms which are a progression of NHS England’s ‘Five Year Forward View’ (actually published seven years ago) and the NHS Long Term Plan (published in 2019).

Several changes to the way the NHS is run and organised, are happening at the same time – legislation is required for some but not all so we will focus on the changes rather than the legislation.

The Objectives are:

  • To return a degree of power to the Secretary of State (SoS) and Government in respect of the running of the NHS – the Lansley reforms created a quasi-independent NHS
  • To simplify the NHS commissioning and regulatory framework – we currently have NHS England and NHS Improvement (NHSEI) and clinical commissioning groups (CCGs) as statutory bodies and ICSs that do not have formal (legal) legitimacy but are increasingly making decisions about strategy, budgets and services at a regional level. There are also integrated care partnerships developed at a “place” level.
  • To provide flexibility in respect of competitive tendering and procurement rules – i.e. to allow the SoS and NHS to determine what and when to implement a competitive process.
  • To reduce internal competition between NHS providers – to promote integrated working, this includes general practice.
  • To refine some elements of the ‘purchaser/ provider’ split introduced in the 1980’s – in particular reducing the reliance on ‘payment by result’ through changing to providers working together
  • To promote more effective partnerships across Health and Social Care – in particular to strengthen the links between the NHS and Local Government

The way this will be achieved (according to the White Paper):

  • A new Health and Social Care Act which will:
    o Return overall control back to the Government
    o Amend the competition rules
    o Simplify the NHS organisational arrangements – incorporate the roles of CCGs, and elements of regional NHSEI functions, into ICSs
  • The development of an ICS (on regional footprints) and Integrated Care Partnership (ICPs) usually on LA footprints. This ‘new’ organisation model will:
    o Incorporate the current NHSEI, ICS and CCG commissioning functions into the new ICS
    o Enable the tactical/local commission functions of the CCGs to be devolved to ICPs – although it is likely that some may be retained at an ICS level
  • The promotion of integrated working.
    Examples of what will feature in and be pushed through the legislation include:
    o requirement for all provider trusts to work in partnership at an ICP level
    o development of primary care networks (PCNs), promoting integrated working between practices and providing the representation of general practice at an ICP and ICS level.
    o requirement to further develop integrated working with local authorities and other partners.
    o New financial systems which will increasingly be based on managing within set budgets across organisations.

The potential implications for general practice

1) PCNs will become the primary mechanism for ensure general practice (as a provider) is represented at ICS and ICP level

2) Service changes will increasingly be organised and delivered through PCNs.

3) Commissioning and contracting for general practice services will be managed by the ICS (strategy/ general medical services (GMS) contract etc) and over time the ICP (local enhanced services, care pathways etc.). The pace of devolution to ICPs will be determined by each ICS.

4) PCNs / federations/ Local Medical Committees will be the critical bodies in respect of nominating GP leaders to support and influence the system. CCG style governing body with elected representation will disappear

5) The ICS/ NHSEI will determine if and why to competitively tender services – there will be requirements with value for money being the key component.

6) The Government of the day will be more able to direct policy – this could include changes to general practice, including GMS. In particular it is likely that there will be a drive to reduce perceived monopoly provision.

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