The bombshell decision by the Government to abolish NHS England has received mixed responses. The right-wing tabloids have rejoiced (‘Finally! Patients To Be Put Before NHS Bureaucrats’ cooed the Daily Mail); some ex-Conservative ministers have lamented their own failure to make the same decision; and health think tanks (having seen this sort of thing many times before) are speculating about the wisdom of yet another attempt .
While attention has largely focused on the cuts and job losses at national level – ‘the world’s biggest quango’ as the Prime Minister put it – much less consideration has been given to the regional tier of NHSE, consisting of the 42 Integrated Care Boards and Systems (ICBs/ICSs). Here too, cuts of around 50% in staffing are anticipated. Does this matter? And what opportunities might it give rise to?
What happens to this tier most certainly does matter. It has been responsible for spending around two-thirds of NHS England’s annual budget and is tasked with working in partnership with councils and the voluntary sector to make local populations healthier. Starting out as essentially voluntary arrangements, ICBs/ICSs were given statutory powers and budgets only as recently as July 2022. They vary in size, geography, and demography, with most spanning more than one local authority – the largest is here in the North East and Cumbria, making key decisions for a population of over three million people.
The abolition of NHS England
The abolition of NHS England clearly /ICSs have a dual raison d’être that sits well with two of the government’s national priorities: shifting the focus from treatment to prevention; and moving from silo working to cross-organisational partnering.
Much of what contributes to our health status lies outside of mainstream healthcare; rather it sits within having access to an adequate income, secure housing, stable employment, and a safe neighbourhood. ICBs/ICSs were created precisely to help deliver on this agenda – to improve health outcomes, reduce health inequalities and drive local social and economic development. This also ties in neatly with the principles underpinning the imminent 10-Year NHS plan – a shift from treatment to prevention, and from hospital to community.
Crucially, this broader mission depends upon joined-up services and support across the NHS, local government, the voluntary sector, private care providers and others; a shared mission to collectively meet the needs of local people. This has been the unfulfilled holy grail of public policy for several decades.
Study on ICBs/ICSs
Achievements hitherto seem to be limited, not least because the regional tier has been unremittingly accountable to the central tier rather than to a regional collective of kindred partners. One early study concluded that the pressure on ICBs/ICSs to reduce demand on primary and emergency care, and tackle elective backlogs, detracted from their key goals of improving population health and prevention.
The inter-organisational jigsaw is now further complicated by the rapid extension of the metro-mayor model across England. The government’s devolution white paper had set up an expectation that ICBs would engage with mayors during the chair appointment process, would consider the mayor for the position of Chair or co-Chair, and would involve mayors in the setting of priorities and development of plans. This would have been a novel departure from previous practice, and one that is now uncertain.
So, where next for NHS ICBs/ICSs?
On the one hand the future looks bleak. As part of the announcement on the abolition of NHS England centrally, staff working in ICBs were told that half of them would be losing their jobs. The expectation is that this will lead to de factomergers, along with the organisational and personal upheaval that this will create. In such a circumstance a raft of weakened ICSs suffering from low staff morale could retreat into themselves, await instructions from the Department of Health and Social Care, and pay little more than lip service to their mission of improved outcomes for local health and wellbeing.
But there are other options. The first is one that devolves more NHS decision-making to the regional tier. As recently as last November, the Health Secretary, Wes Streeting, outlined a sweeping plan for ‘triple devolution’ – power and resource was to be pushed out of Whitehall to ICBs/ICSs, to providers, and to patients. The centre, it was said, would be much smaller, issuing far fewer ‘diktats and demands’. If Streeting is serious about devolving NHS decision-making, the regional tier would need to be strengthened rather than decimated.
NHS regional inter-organisational working
Another option focuses upon the importance of regional inter-organisational working, rather than devolved silo working. The emerging mayoral combined authorities – all of which have full representation from their constituent local councils – would be crucial to this model. These authorities already have key powers relating to the wider determinants of health such as employment and skills, housing, planning, and transport. Some, such as the north-east mayor, Kim McGuiness, have made the easing of child poverty their guiding mission– a clear health-related policy.
In such a joint configuration, coterminous boundaries between combined authorities and rejuvenated ICBs/ICSs would be a prerequisite. Requirements on mutual representation on each other’s governing bodies would need to be the norm, as would performance measures that reflect the product of shared endeavour and joint investment. And there will be lessons to be learned here from the Scottish experience of Integrated Joint Boards and from the pioneering joint working across health and local government in Greater Manchester.
Transfer responsibility and funding for the NHS to combined authorities
The most radical democratic option would be to transfer responsibility and funding for the NHS to combined authorities themselves – a step recently proposed by the think tank, Reform. The authors claim that this would be the best way to bring the NHS into a world of stronger local democracy and subsidiarity, and help it shift from a sickness model to a health and wellbeing service. After almost 80 years of highly centralised control of the NHS, a reopening of the Bevan-Morrison debate on governance and accountability is perhaps long overdue.
The danger with the unexpected abolition of NHS England, and the associated decimation of its regional tier, is that the modest financial savings accrued will become an end in themselves. There are no details whatsoever as to the future of ICBs, leading to the danger of a governance vacuum. What is needed is a strategy, a sense of direction, a plan, and a more responsive and accountable health system sensitive to the needs of communities.
Almost by accident, a window for joined-up devolution has been opened. Is there any chance we have a government with the imagination to climb through it?
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