Streeting should empower ICSs, not undermine them

As the election draws closer and the polls continue to point in one direction, attention is turning to the specifics of what Labour, if given a mandate, will do in power.

The most pressing issues for the health service right now are financial challenges. Will the likely future health and social care secretary, Wes Streeting, want to start his tenure presiding over an NHS forced to spend the rest of the year making widespread staffing and service cuts because it can’t balance the books?

If in-year money is made available, will it address the broad structural deficit or be channelled towards the new government’s priorities? One of these priorities is already set in stone; that of reducing the elective waiting lists, backed up by an ambitious one-parliament promise. The way the new Labour secretary of state, if elected, will go about this is already subject to much advice and speculation.

I know from people advocating to Mr Streeting’s team, and from people who have heard them do so, that one view on reducing elective waiting lists is for the Department of Health and Social Care to bypass integrated care systems (ICSs) and seek to directly fund, mandate, and hold accountable acute trusts.

Those holding this position acknowledge the importance of systems to other key priority areas such as urgent and emergency care and primary care reform but, the implication is that addressing the elective waiting list is either too urgent or too acute focussed to be slowed down by going through ICSs.

Reducing waiting lists is not simply a matter for acute trusts; driving down elective waiting lists is a system-wide issue and as such demands a system-wide response

There are two obvious problems with this approach.

First, reducing waiting lists is not simply a matter for acute trusts; driving down elective waiting lists is a system-wide issue and as such demands a system-wide response. We know that systems have already developed elective recovery plans using NHS England’s (NHSE) designated elective recovery fund. One of the priorities in NHSE’s planning guidance, as per its oversight framework, is that provider oversight should be done by NHSE “with and through integrated care boards”.

As well as the key role acute trusts play in elective care, it is important to acknowledge the crucial part other services across a system, including primary and community care, also have in reducing the numbers of those waiting and supporting those who are.

There are many examples of where systems are working to reduce the elective waiting lists. In Sussex the ICS has worked with partners including Sussex Community Trust to offer local people community appointment open days, where those on MSK waiting lists have been invited to meet and interact with a wide range of health care professionals and services.

In just one day almost half of those on the waiting list were either discharged or opted for active self-management of their condition while waiting. There is now a similar scheme running in Wandsworth orchestrated by South West London ICS.

With staff and financial capacity limited, progress on electives can be slowed or even reversed if front door emergency department demand and back door discharge issues are not being successfully addressed. As best practice in several ICSs, for example Norfolk and Waveney, shows, these flow-related issues are best addressed through collaboration within and beyond the health service.

The second problem lies in any suggestion or messaging from the likely new secretary of state that he wants to bypass ICSs to achieve the high-profile waiting list reduction ambition.

Given that systems are still in the foothills of their longer-term development, were “born into a storm” (to use Nicholas Timmins’ phrase) and were subject to 30 per cent cuts almost as soon as they were created, we know system working is still a project in progress.

The environment has yet to be created in which systems can thrive

Anyone who has been around the NHS for any time will know its history is littered with abandoned organisational forms: regional health authorities, SHAs, PCTs, CCGs, the list of acronyms goes on.

To sideline ICSs at such a crucial stage in their development and just as they are starting to flourish could be seen to put their future in doubt and would also undermine Labour’s commitment to avoiding major reorganisation.

A mission-driven government could instead provide the investment, focus and support needed for ICSs to take forward their wider strategic objectives on improving population health and reducing health inequalities.

The Conservative government should be applauded for creating ICSs and giving them a statutory basis, as should Labour for committing to retaining the current structure of the English NHS.

But as Patricia Hewitt pointed out last year in her review of ICSs, the environment has yet to be created in which systems can thrive. To date, progress on the review’s recommendations has been slow. If elected, an incoming Labour government should grasp the opportunity to let ICSs fulfil their potential and not – even if accidentally – undermine them.

Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on X @ConfedMatthew