Healthwatch Kingston upon Thames welcomes the decision by NHS England to consult on its proposals for legislative change, intended to clarify and put on a statutory basis the position of Integrated Care Systems (ICSs). Our responses to the questions posed by the consultation document are set out below but we would also like to raise some wider points.
Given their growing strategic role, putting ICSs onto a statutory basis is sensible, but there needs to be more clarity about their governance and accountability, including the freedoms of Foundation Trusts vis a vis the ICS. We consider that independent local Healthwatch should have a place on the governing body/board of the ICS; this will need additional capacity (including funding).
We are also very concerned at the lack of focus in the document on the role of patients, service users, carers and their advocates (including Healthwatch), particularly at the strategic and decision-making level, despite the mention in the document (e.g. 1.12 ‘the right priorities for residents’). This involvement is particularly important in the light of considerable service changes during the pandemic, including expedited discharge which may put undue pressure on carers.
There are currently legislative requirements on Trusts and Clinical Commissioning Groups (CCGs) to involve the public. These include public consultation, and consultation with local authority health scrutiny committees, on proposed substantial variations in services. The role of local authorities in undertaking health scrutiny will need to be reviewed and revised in response to the development of ICSs. If local authorities enter into ever-closer partnership with the NHS it is debatable whether there will still be enough capacity and independence for back-bench councillors to undertake effective health scrutiny. Similarly, the position of Health and Wellbeing Boards will need to be reviewed.
We welcome the proposed legislative changes to remove many elements of the quasi-market such as the tariff and compulsory tendering; this should have the added benefit of reducing transaction costs and enabling local restructuring of care where appropriate. We would welcome clarity on whether it may also address the geographical distribution of general practice. However, the clinician oversight of secondary care provided by local commissioning should be retained in some way.
The added ICS focus on population health is ambitious and laudable, particularly working closely with PCNs, but may be challenging in the light of the recent abolition of Public Health England. DPHs should in any event have key decision making roles in the new structures. The metrics will need careful selection in order not to further disadvantage ICSs serving populations with poorer health outcomes. In general, performance metrics should be granular and available at place level, to enable monitoring of services.
We welcome the recognition of the importance of place and the need for strong, integrated, governance at place level which includes Healthwatch. We would however like to see greater clarity on how commissioners and providers of services will work together at place level and in particular we consider that the full benefits of place working will not be realised until the provision of social care is reformed and has a more reliable funding stream based on evidenced based need.
Local determination of ways of working will need to be balanced with a reasonable amount of consistency, in order not to create postcode lotteries and to make use of appropriately resourced voluntary and community sector organisations. Flexibility should not be at the expense of overall accountability and effective patient and service user voice. Consistency of working practices is also important for organisations such as ambulance services which need to work with a multiplicity of partners.
To assist what we hope is intended to be a transition from a traditional command and control resource structure towards regional empowerment and decision making, will require a structured framework for efficient local collaboration supported with the necessary resources. Without such clarity, and the resources required for delivery, currently engaged partnerships risk being marginalised.
Q1: Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
ICSs are already playing a key strategic role, and it is likely that their importance will grow in the years ahead. This reflects a deeper shift in the way the NHS is evolving, from a quasi-market to collaboration. We welcome this. Relying almost entirely on voluntary collaboration to make this work seems cumbersome and risky, and we therefore agree that it would be sensible to put ICSs on a more formal, statutory, basis.
Q2: Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
We agree that option 2 is the logical direction of travel, and that it would be sensible for the legislation to provide for its adoption. We are concerned, however, that the current options do not provide adequate clarity of accountability, in particular to patients and service users.
We welcome the recognition (para 2.38) of the importance of patient insight to ‘inform’ decision-making. However, this alone is insufficient. A strong patient and public voice is also needed at the decision-making levels themselves, whether local (‘place’) or strategic (ICS). For example, although local Healthwatch is a mandatory member of the ‘place’ structure, it has no equivalent seat at the ICS Board. This is a major omission and clarification in the final legislation would be helpful.
More broadly, both provider Trusts and CCGs currently have established mechanisms - often mandated by statute - to consult patients and the public, and to ensure that their voices are heard at strategic governance and decision-making levels. In addition to local Healthwatch, these mechanisms include the roles of (elected) Trust Governors, Trust Non-Executive Directors and CCG Lay Members (including Lay Members with specific responsibility for patient and public involvement). Although ICSs will have greater decision-making authority than either Trusts or CCGs (if CCGs continue at all), the current proposals are silent on how the ‘lay’ voice, particularly of patients and the public, would be represented with authority at this governance, or decision-making, level.
The consultation document envisages collaboration at ‘place’ level, which we welcome. However, there seems to be a risk that decision-making on acute services could move further away from primary and other local services, into the hands of ‘provider collaboratives’ working solely at ICS level. This could be a step backwards, away from the goal of greater collaboration and integration between acute and non-acute services. Similarly, we could lose one of the genuine benefits of the current model - the ability of local primary care clinicians to scrutinise and challenge acute services, through the contractual and quality mechanisms of CCGs. The fact that local GPs have mechanisms for challenging acute providers and holding them to account is an important safeguard for patients and service users, and something we would want to see retained in any new model.
The proposals for ‘provider collaboratives’ make no mention of patients or patient representatives. We recommend that all such ‘collaboratives’ be required to include patient and service user voices at the governance level. Similarly, we note that pathway design will be led (para 2.63) by ‘provider organisations and others’, but with no explicit explanation of ‘others’ including voluntary and community sector organisations or obligation to engage with patients, service users and their representatives. We recommend that patient and public involvement be a mandatory part of all such exercises.
Q3: 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?
We think there need to be some clear principles, to ensure consistency, and that ICS Boards remain accountable to patients and the public.
There are currently several accountability models, designed to ensure key decision making (‘governance’) is not simply in the hands of executives. Trust Boards require a lay majority (plus an elected Council of Governors), and CCGs a clinical majority (except when commissioning GP services, at which point lay members take control). Local authority decision making is by elected councillors. The consultation document makes no equivalent proposal in relation to ICS Boards. The lack of any guiding principle for the governance of ICSs is a major omission which needs to be addressed.
As a minimum, and as noted above, it should be mandatory for ICS Boards to include local Healthwatch representatives. This will require new and collaborative activities by local Healthwatch on a wider geographical level than hitherto, but without detracting from its role at place (and indeed locality or PCN) level. We therefore recommend that NHSE and Healthwatch England identify additional funding to ensure local Healthwatch can meet the new challenges - without detracting from the local Healthwatch focus on ‘place’.
Q4: Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned why NHSE should be either transferred or delegated to ICS bodies?
We think it would be helpful for further commissioning decisions to be made locally, except for very specialist commissioning. This should be considered case by case, and we take it as axiomatic that the necessary funding will also be transferred.
Dr Liz Meerabeau, Chair, on behalf of Healthwatch Kingston upon Thames (8 January 2021).