Integrated care
and much of the delivery of local priorities will rely on the culture of local government and the NHS organisations working closely, while being responsible and equal. This is not a given, especially if the purse strings are held by the Integrated Care Boards, and they will only have one local representative, whereas the NHS will have four – the chief medical officer, the chief nursing officer and further representatives from a local Foundation Trust and General Practice. The Review is fairly quiet on the development
of appropriate cultures and behaviours but recognises that a lot of work is still to be done to enable ICSs to work effectively, as the current cultures of the NHS, and local government, particularly, vary enormously. The NHS is not, for example, democratically accountable to local people and is much more tightly controlled and regulated through national targets, priorities and funding streams, than local government. Local government also has much greater flexibility over local spending, albeit in the context of huge cuts in central funding. There has been much talk by central Government for a number of years to devolve more power to local government via deals on devolution.
Variation across the country The different ICSs should be developing local plans according to the health and care needs of the local population. If the ICS is to tackle health inequalities, it will be interesting to see how managing health conditions, such as obesity, diabetes and mental illness, are impacted by the changes to the oversight and governance by
the joint authorities and spending power of the ICSs. Factors such as housing, employment and environment will become far more important to reduce health issues, ensuring that the NHS will have to work outside the present boundaries of healthcare. The review identifies that each ICS should be enabled to set a focused number of local priorities and agree their measurement. These should, it suggests, be equal to national targets and be spread across health and social care. It is difficult to imagine a world where central
Government is not responsible for performance measures such as A&E waits, waiting lists for
surgery and many others. How will the public respond to the regional and local differences in healthcare provision? Local flexibility has, to date, been the role for the vanguard STPs (remember them?) where encouragement to tackle local issues was the top of the list of problems to be managed. There is a great deal of difference between the size and complexity of the different ICSs, as well as their development and maturity. The Review suggests that ten of the most mature ICS organisations should be singled out as so-called ‘HARPs’ (High Accountability and Responsibility Partnerships). They would be able to have greater autonomy and the review5 suggests that they should be able to deliver: l A radical reduction in the number of shared national priorities and KPIs.
l Agreed accountability for small number of shared priorities.
l Greater financial freedoms for local partners. l Effective data sharing. l Light touch accountability framework.
It can be guessed at that eventually all ICSs should be working towards this ambition – unless of course the politics and mechanisms of the ICS organisations are changed by a change to national Government. However, it can also be seen that, as local priorities become more prevalent than national targets, there will be great divergence between services in one area of the country and the next, dependent on the local issues and strategic plans. This will need to be carefully messaged and promoted as it develops as, generally, local issues are less well known by the general public than national ones. It also gives less Government input, which has always been a huge element
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www.clinicalservicesjournal.com I June 2023
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