New proposals put forward by NHS England (NHSE) have called for a re-structuring of way in which decisions are made within the National Health Service in England. In a consultation paper, NHSE has put forward a complete adoption of Integrated Care Systems (ICSs), which would further devolve commissioning activity to a local level so as to “remove barriers to integration across health bodies and with social care…help deliver better care and outcomes for patients through collaboration, and to join up national leadership more formally”; and, importantly, to deliver on “a renewed ambition for how we can support greater collaboration between partners in health and care systems to help accelerate progress in meeting our most critical health and care challenges.”
Transform Hospital Group welcomes (THG) this clearer focus on further devolving authority for healthcare delivery to ‘place-level’, but notes that the systemic shift should acknowledge and make a clearer emphasis on the critical and additive role that independent providers specifically can and should play in supporting the delivery of care at a local level across the country – as exemplified by the landmark collaboration achieved during the COVID-19 pandemic. THG believes that it would prove a missed opportunity to establish a full “whole-systems” approach to the delivery of healthcare as we transition beyond the immediate pressures of the pandemic, if independent providers were to be seen as ‘outsiders’ to this new model of care. Therefore, greater consideration should be given as to how the independent sector can be appropriately integrated into ICS strategic planning and models of collaboration between NHS institutions and providers, in the interests of delivering world-class care that draws on the strengths, expertise and capacity of all partners and providers across the healthcare ecosystem, remaining free at the point of use, everywhere in England.
The publication of the ICS consultation comes at a time when health and social care provision has been subject to challenges on a scale not seen in the history of the NHS. The COVID-19 pandemic has tested the resilience and capacity of health services in England and provided opportunities to consider how to optimise the provision of health and social care in such a way that continuity of care across the spectrum of patient needs remains possible even in the most extraordinary of circumstances.
It is evident that the pandemic will hold lasting implications on the delivery of healthcare within in England, and the collaborative nature of addressing the pressures brought about by COVID-19 across a huge range of organisations of all sizes must remain. In particular, the partnership between the NHS and independent providers brought about by the pandemic has helped catalyse innovations within the NHS which have been prevalent amongst the independent sector for a number of years. The collaboration also instigated a more joined-up way of thinking, building on the strengths of all parties.
Drawing on its experience of supporting NHS Trusts in the delivery of elective care during the pandemic, THG has consistently called for the further localisation of decision-making and authority for taking commissioning decisions, driven by the need for collaboration at place-level in order to address the requirements of local populations. THG therefore welcomes the broad premise of NHSE’s proposals – to deliver a more collaborative model for decision-making within the healthcare services which delivers on the needs of populations at a local level. Indeed, THG has consistently stated that such a “whole systems” approach would provide cost-efficient and innovative healthcare services to patients which is free at the point of use and delivers value for taxpayers.
THG’s perspective and recommendations
While THG welcomes NHSE’s calls for greater levels of collaboration to benefit the needs of communities at a local level, there is a lack of clarity in the proposals as to the capacity in which independent providers will be able to contribute to the delivery of services under the anticipated structure for ICSs. For example, it is unclear as to whether independent providers are assumed to be integrated into a wider and more general definition of “providers” within ICSs, or whether the scope of “providers” is restricted to the normal definition of NHS providers (i.e. NHS hospital, mental health, community and ambulance service providers). THG would welcome further clarity – and specificity – on the role that independent providers can play in supporting the delivery of care at place-level, such as being integrated at a strategic level in the various new and dynamic ways of working set out in the consultation document.
Therefore, while it is an important step that NHSE has recognised the need for greater levels of collaboration, THG believes that without clear opportunities for engagement and integration of independent sector providers within the proposed structure, an essential element of the healthcare landscape will be missing from the transformation, meaning the present proposals appear to fall short in bringing about a truly holistic “whole systems” approach that will enable patients to access the very best facilities, clinical expertise, technology and innovations in healthcare, wherever they live.
This is notably evident in the proposition for provider collaboratives, whereby all NHS provider trusts will be expected to participate in joined up systems at place, regional or indeed national level. Again, this is positive in the context of the further localisation of services, but THG believes that such provider collaboratives should be approached in a holistic manner and include representation from the independent sector – on an independent and non-commercial basis – thus enabling the well-documented expertise and experience from outside the NHS to contribute to strategic planning at place-level. The structure that such representation may take is for further discussion (acknowledging, for example, the need to rule out any ‘conflict of interest’), but may take the form of a strategic advisory board made up of independent sector partners represented within the relevant geographic region.
Indeed, each of the principles highlighted in NHSE’s consultation document that provide rationale for provider collaboratives would benefit from the engagement of the independent sector; namely, higher quality and more sustainable services, the reduction in the variation of patient outcomes, a reduction in health inequalities, better workforce planning and more effective use of resources. There is little doubt that the current proposals stand to benefit local populations – particularly if they bring about greater integration of local councils, authorities and the voluntary sector into the NHS infrastructure – but there is clearly a further role for the independent sector to play, highlighted by the COVID-19 pandemic, which must be recognised and addressed.
As such, in response to the third consultation question set out on page 32 of the document (“do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?”), THG agrees that membership should be sufficiently flexible so as to allow systems to address the requirements of individual populations, but believes that along with the third sector and local authorities, the independent healthcare sector ought to be identified specifically to be drawn on as required by public health bodies, as appropriate and relevant to the place in question.
ICSs should therefore be given sufficient guidance as to how to make best use of the independent sector from NHSE leadership, such that the opportunities for greater integration into planning benefits the local population contributes to driving efficiencies and optimises value for taxpayers. This is particularly pertinent in the current context of COVID-19, where ICSs will play a central role in supporting the NHS as it addresses the needs of populations beyond the pandemic.
To that end, in response to the final consultation question (Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred to delegated to ICS bodies?), THG absolutely agrees that services currently commissioned by NHSE should be transferred to ICSs where they are relevant to the delivery of healthcare within a particular place or wider region. This would build on the positive collaborative experience gained during the COVID-19 pandemic, in which stakeholders across the healthcare ecosystem worked together to address the needs of the population. However, it would also address some of the shortcomings that were witnessed during the pandemic – experienced by THG first-hand – whereby Trusts that wished to access local capacity quickly were constrained in their commissioning activities due to established NHSE structures at a national level.
The capacity and expertise of the independent sector stands to play a pivotal role in the NHS’ recovery from the pandemic, holding the ability to provide essential services in order to address the backlog of patients requiring elective care – which is likely to be felt across the NHS for a number of years. It is for this reason – coupled with the innovative nature of the independent sector – that representatives of the independent sector should be included in the operational structure of ICSs, in appropriate forums.
THG would clearly welcome the opportunity to participate in such a way, bringing to bear our expertise in various clinical areas, building on the success of our collaboration with the NHS during the pandemic and our commitment to supporting the communities surrounding our facilities.