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Integration and innovation: the latest NHS reorganisation

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The latest policy paper from the Department of Health and Social Care, entitled Integration and innovation: working together to improve health and social care for all, outlines the proposals for another reorganisation of the NHS and, by default, the social care sector.

COVID-19 and the need for change

There is no doubt that the COVID-19 pandemic highlighted, in all its glory, all that worked, while shining a light on areas that made it more difficult to deliver the services required by fast-moving and widespread events. It exposed, too, the myriad organisations that support the NHS, some of which struggled to know their role. Or – worse still – it showed ministers were unsure of which tasks should be allocated to which organisation.

They say it takes more than three miles of open sea to turn an oil tanker. During the pandemic, the inability of the system to provide a timely response, when quick action was needed, was apparent – to the sometime frustration of ministers (and the public). It was also clear that the response was more hampered by structures rather than funding: never before has so much government money been handed out with so little resistance from the Treasury.

Many argue that now is not the time for another reorganisation of the NHS. But a key theme within the government’s response to COVID-19 was that the NHS could fail, hence the ‘save the NHS’ mantra. It has to be fixed because it simply needs to be better. It needs to be now because, if not now, then when?

We have a clear insight into what needs to be changed to make the system work. There is a realisation that internal, rather than external, factors pose the biggest obstacles: the overly-bureaucratic, disjointed patchwork quilt of NHS trusts, clinical commissioning groups (CCGs), local authorities and private contractors, none of which are geographically aligned, but that, in the case of CCGs and local authorities, share funding mechanisms for care packages, actually gets in the way of providing good health and social care. And there is a desire to fix it. The conditions are ripe for change.

A system pulling itself apart

Worse, before the pandemic, the truly national nature of the NHS was disappearing with CCGs and local authorities taking their own decisions, and Public Health England (PHE), now ensconced in local authorities, doing the same. The system was pulling itself apart. Reorganisation had to come, as it became apparent that the previous reorganisation in 2012, under then Prime Minister David Cameron and Health Secretaries Andrew Lansley and Jeremy Hunt, had hindered, rather than helped.

And so to the latest policy paper, published on 11 February 2021. Much of the 2012 changes were transactional – meaning it was layers of bureaucracy, relying on figures, not data systems. But ask anyone in the NHS and the best changes have been in technology and systems. During the pandemic, these worked! The pace and scale of collaborative innovation that worked so well during the pandemic is therefore to be built on and the recognised obstacles removed. This is reflected in the three themes that are highlighted in the policy paper:

 

  • Working together and supporting integration.
  • Stripping out needless bureaucracy.
  • Enhancing public confidence and accountability.

The time of the integrated care system has arrived

Integrated care systems (ICGs) have been taking shape since 2017/18. These are now to be rolled out to cover the whole of England by the end of this year, with appropriate legislative backing (health and social care being the responsibility of the devolved administrations, this policy paper does not cover Scotland, Wales or Northern Ireland).

It also appears that the 2019 consultation on the NHS Long Term Plan proposals for legislation have been listened to and will be taken forward. The three important principles of the 2019 consultation still stand: the foundation of any legislative action should be to solve practical problems, avoid disruptive top-down reorganisation, and have broad consensus within the NHS. Lessons have also been learned from the pandemic, so matters relating to public health, social care, quality and safety will be included in the new proposals.

Practically, this will see statutory ICS, comprising an ICS NHS body and a separate ICS health and care partnership, working together in a set geographical area, across of all on England. For the first time, the Care Quality Commission will have a role in reviewing the working of the ICS, which will include local authority functions, as part of the health and care partnership.

There is to be full consultation on these proposals, as well as the long-awaited social care changes. The timescales are yet to be agreed. One is for sure: there is mounting pressure to get it right, both for the government and the taxpayer, and the general public and users of the service.

Conclusion: too close for comfort

The NHS survived the pandemic but it was close – too close. That is why these changes, whatever they turn out to be, need to make the NHS both more resilient and better able to react quickly and effectively to similar events. To keep us, the individuals who rely on it, safer. It’s also why is needs to be now: after COVID-19, who knows what the future has in store.

Margaret Ross-Sands

W&P Assessment and Training

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