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RCP response to NHS E consultation on integrated care legislation

In January 2021, after consulting internally the RCP submitted the below response to the NHS England consultation on legislative changes to deliver more integrated health and care.

The consultation was the first step in the process of developing legislation to give more powers to integrated care systems, and implementing aspects of the NHS Long Term Plan.  

Executive summary of RCP response 

  • We support the principle of putting ICSs on a statutory footing, to provide the framework for a more integrated approach to delivering healthcare.  

  • Greater clarity is however needed on the practical implications of the proposals, especially given the ongoing disruption to services resulting from COVID-19 and nervousness among the workforce about another disruptive top-down reorganisation. 

  • Legislation would need to be underpinned by strong measures to tackling health inequalities, which have been exposed and exacerbated by COVID-19. 

  • Close attention needs to be paid to the workforce planning element of integrated care for it to truly work. The development of a national workforce accountability framework is going to be key and must be agreed between the NHS, HEE, government and other relevant organisations. 

  • Greater integration and working at a local level between organisations is crucial, but we need to make sure that all relevant organisations and bodies are included, such as the voluntary, community and social enterprise (VCSE) sector. 

  • We look forward to seeing and engaging with the detail in the coming months, both the legislative proposals and how they will be communicated. 

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? 

Strongly agree/Agree/Neutral/Disagree/Strongly disagree 

The RCP believes there is a strong case for putting ICSs on a statutory footing from 2022, to provide the framework for a more integrated and collaborative approach to the delivery of healthcare across the NHS and social care. We will need to consider how this change can happen in a phased way, so the practical challenges can be properly assessed and addressed.  

As this and other legislative proposals develop, the practical implications for patient care and ways of working need to be more clearly spelt out. There is nervousness among NHS staff about another ‘top-down reorganisation’, especially in the context of the severe ongoing disruption to services that COVID-19 has caused. It will require a detailed communications plan to ensure broad understanding, as the aims and plans for integration are still unclear to many. We look forward to seeing and engaging with the detail, of both the proposals and communications, in the coming months.  

The pandemic has also exposed and exacerbated existing health inequalities, and legislative change will need to be underpinned by measures to address these inequalities and support greater funding for public health. There will also need to be greater clarity on the role that NIHP will play and where responsibility for population health will sit.  

Workforce planning must also be a central part of these proposed legislative changes. We strongly support the development of a national workforce accountability framework, which needs to be agreed between the NHS, HEE, government and all relevant organisations. 

We also support the introduction of a duty on the Secretary of State to ensure sufficient workforce. Better long-term workforce planning is crucial to the ability of the NHS to deliver better integrated care, and these two mechanisms should together help to incentivise long-term thinking. Close working with the education system will also be needed, for example to expand the number of medical school places available. 

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?  

Strongly agree/Agree/Neutral/Disagree/Strongly disagree 

We agree that option 2 offers a model that provides greater incentive for collaboration, but both options have their challenges.  

Greater collaboration is difficult to achieve but greatly needed; it requires enthusiasm to cross boundaries. Option 2 would provide that, with greater accountability and autonomy at a local level But it is not clear what the full impact would be of a new system, given that the indirect impacts are likely to be extensive.  

It is clear that there is support for putting ICSs on a statutory footing but there are many unknowns and uncertainties among physicians about the full impact each model will have. 

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? 

Strongly agree/Agree/Neutral/Disagree/Strongly disagree 

It is essential that systems have the necessary flexibility to develop governance arrangements that work best for their populations. To enable greater integration at a local level, systems need to be able to work closely with all relevant organisations and bodies, including the voluntary, community and social enterprise (VCSE) sector.  

During the pandemic, with fewer regulatory constraints at the local level, there has been a huge amount of innovation in terms of service delivery and working practices. As we rebuild the NHS, we must learn from this and ensure local systems have this flexibility built-in so they can deliver care in the way that works best for their populations. 

Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies? 

Strongly agree/Agree/Neutral/Disagree/Strongly disagree 

It is important to consider the impact on public health of changes to both ICSs and Public Health England. Local autonomy is important in commissioning services and procurement has been historically challenging. Regional needs vary greatly so transferring authority would enhance the autonomy of ICSs.  

Transparency and clarity about changes would be needed, as widespread confusion about the system already causes problems. This must be, as you say, subject to appropriate safeguards.  

Concerns remain regarding the impact of the change, particularly regional variation. Success often depends on local factors and cooperation, which we cannot allow to impact negatively on patient care. Some regions do not have experience of joint commissioning, so varying levels of initial support will be needed to ensure success across each region. There also needs to be greater flexibility on tariff setting and commissioning should be quality driven. 

Please contact policy@rcplondon.ac.uk if you have any comments or questions about the consultation or the RCP’s work in this area.