Making ICBs performance managers will slow integration

Given the growing demand for healthcare, the core challenge for government is to reform the way we deliver services to better improve the nation’s health if we are to have a financially sustainable health and care system. The new government’s manifesto commitment to 'over time shift resources to primary care and community services' is the right one to address the structural drivers of today’s pressures.

By bringing together system partners to consider how to make best use of collective resources, integrated care systems are the best way to integrate services and achieve this shift care closer to home to improve tomorrow. However, they need to do this while managing performance, quality and access today. In Nottingham and Nottinghamshire ICS, we refer to this as 'managing today and building tomorrow'.

I see a way forward where we can balance these short- and long-term goals if we are incentivised to do so.

"While regulation exists to intervene when severe quality, safety or leadership issues arise, oversight plays a key role in preventing the need for regulatory intervention."

Rigorous oversight and regulation helps drive improvements in the quality of care and is something all system leaders agree on. While regulation exists to intervene when severe quality, safety or leadership issues arise, oversight plays a key role in preventing the need for regulatory intervention. Together, they play a crucial part in improving care, delivering value for money to the public and providing accountability – all vital to a well-functioning health and care system.

Oversight and accountability arrangements are complex. There are national bodies – notably NHS England and the Care Quality Commission – with statutory oversight of integrated care boards and providers. ICBs have a statutory responsibility for ensuring value for public money for the services they commission.

Given that they look right across pathways of care they commission from different providers, ICBs can play a particular role in helping to improve performance today. It is therefore essential that NHS England’s approach to oversight works 'with and through' ICBs, so these functions are not duplicated.

However, in a  survey of ICS leaders the ICS Network recently conducted, regulation and oversight was cited as a barrier to system working and only 40 per cent of respondents felt that system accountabilities with NHS England’s national team are clear.

"This 'middle layer' of oversight has become too crowded and too burdensome."

NHS England recently consulted on its new oversight framework. Sitting in meetings with colleagues and hearing their perspectives, it felt as though NHS England had asked ICBs to take on a greater performance management role, but without rebalancing their national and regional oversight – thus adding a new layer, rather than delegating existing oversight. This 'middle layer' of oversight has become too crowded and too burdensome.

This, of course, is particularly frustrating providers, who feel the weight of different layers of regulation stacked on top of them. And ICB and provider colleagues alike still feel there are too many targets, meetings, requests for data and so on, from the centre.

"...performance meetings with NHS England often focus almost entirely just on short-term operational issues: access and waiting lists."

ICBs are not going to be able to fulfil their full potential as partnerships to reform health and care if they are forced to focus solely on oversight and short-term operational issues. When I speak to my peers, they signed up to the job because they believe our four core aims are the only way to secure the future of the health and care system. Yet performance meetings with NHS England often focus almost entirely just on short-term operational issues: access and waiting lists.

While these issues are essential, we want oversight to be rebalanced so we’re held equally accountable for longer-term goals – transformation, shifting towards prevention and care closer to home and engagement with communities at place and neighbourhood level.

To both manage today and build tomorrow, ICBs need to balance their twin role in system oversight and system convener. In order to do so, we need the right operating model. ICSs need to have the right leadership in place to deliver transformation; regulators must support a focus on short- and longer-term priorities, while aligning with the multitude of improvement resources and expertise that already exists both nationally and locally; and we all need to get better at sharing best practice to support self-directed improvement.

There is a lot of work to be done to get there. Providers need to see themselves as partners within systems. ICBs need to make sure they do not reinforce command-and-control behaviours. And the government and national bodies need to work with and through ICBs.

There are examples of where this is already going well, such as in the north east and Yorkshire, where the NHS England regional team works with the ICBs on the basis of improvement support, trust and mutual respect, rather than top-down performance management. Norfolk and Waveney’s quick improvement on ambulance waiting times was enabled in part by the supportive dynamic between the ICB, providers and NHS England regional colleagues to develop a cross-organisational approach to risk.

Given its importance in improving patient safety and quality, getting system oversight and regulation right will be crucial to enabling the government in achieving its ambitions to devolve, shift to prevention and move care closer to home. Fortunately, the Hewitt review and Dash review will provide a blueprint to do so.

Dr Kathy McLean is chair of Nottingham and Nottinghamshire ICB, chair of Derby and Derbyshire ICB, and chair of the NHS Confederation's ICS Network. 

You can follow Kathy on X at @KathyMcLean13