Trust and ICB leaders must resist the temptation to blame others for the NHS’s woes

As the dust settles on the publication of NHS England’s planning guidance for the coming financial year, and as leaders across integrated care systems (ICSs) digest in greater detail what it will mean for them and their systems, one thing is clear: the next year will be very stretching. 

Integrated care board (ICB) leaders share the government and NHS England’s ambition and determination, as set out in the planning guidance, to improve access to care, and deliver more efficient services.

The guidance details some welcome changes that the NHS Confederation has been calling for on behalf of its members. These include reducing the overall number of targets, devolving more funding and decision-making to systems, and increasing flexibility in payment systems to trial new financial incentives.

Recovery and long-term transformation

Unsurprisingly, the focus of this guidance is recovery. The government remains concerned about the size of waiting lists, worsened by the winter months’ impact on services, and rightly so. 

But in truth, we also find ourselves in uncharted territory in terms of the difficult choices we as leaders will be forced to make about the services we can provide to patients. For example, we may need to move resources from hospitals to build neighbourhood teams. 

We know we can’t just continue to cut services, right-size our budgets and cut our waiting lists. We also need to reform the system so that it’s more sustainable and works better for our communities.  

Efficiency and productivity are good starting points before cutting services - for example, in reviewing infrastructure costs and looking closely at what we can consolidate or stop duplicating. Enhancing frailty models will prevent exacerbations or admissions, and effective use of population health information can help us increase vaccination rates and link agencies at places or neighbourhoods to promote healthy or active lifestyles in our communities.

Despite a 4 per cent uplift in the Department of Health and Social Care’s spending at the Budget – generous compared to other departments and relative to the growth of the economy – there is no hiding the fact that this is an exceptionally difficult financial situation. 

Alongside the planning guidance, every trust and ICB will receive productivity packs outlining where reducing variation in service delivery and use of resources could help to deliver the efficiencies needed. This practical help from NHS England is welcome, and we have heard positive feedback about these already.

System leaders should approach these in good faith and challenge themselves, and each other, to find further savings. This will include in familiar areas: temporary staffing, length of stay, corporate services, off-patent medicines, Continuing Healthcare, and primary care prescribing. 

It is also helpful to see that the health and social care secretary has acknowledged that difficult decisions will need to be made – I know most ICBs will already be making these tough calls alongside their partners.

For example, in Nottingham and Nottinghamshire, our value-based commissioning policy restricts access to low-value procedures, and we have also rigorously applied the NHS guidance around joint packages of care and CHC eligibility, reducing cost but ensuring quality is maintained and in some instances enhanced.

Heading into extremely choppy waters, system leaders must be supported both publicly and privately by local politicians and policymakers alike

Working with system partners, within the NHS and beyond, focused on improving the health of the population remains a key strength of ICSs to help with meeting the expectations. 

In the face of these challenges, the balance of focus between recovery and reform must not become overly distorted. It is here that the ten-year health plan will be critical. It will provide the longer-term narrative and set the trajectory and momentum for delivering the government’s three shifts. 

This is where I hope the plan will add more meat to the bones. How will we as leaders be given the tools, resources, and freedoms we need to help us turn innovative ideas into reality? How will we actually move care closer to home and improve population health at the scale and speed necessary to change the service we provide to the public?

The road ahead

This coming year must be the standout year. It must be the year we get real about the need for lasting transformation, changing how we deliver health services for the better for decades to come. All parts of the system – including neighbourhood teams, primary care networks, trusts, and ICBs – will have a role to play in recovery and reform.

Crucially, when placed under serious financial and operational strain, leaders within providers and ICBs must fight the instinct to look for others to blame and instead work together to find shared solutions. The system that has developed over the last few years may be pushed to its limits. 

Heading into extremely choppy waters, system leaders must be supported both publicly and privately by local politicians and policymakers alike. 

This is where the hard reality of the government’s 'reform or die' mantra will kick in. It is welcome that the planning guidance signals that NHS England will back and support system leaders to do this, and while many newly elected MPs will oft repeat the government’s three shifts rhetoric, it may prove harder for them to stay steadfast when the local electorate is faced with the closure of a local service. This is where the central government must stand firm.

NHS leaders know only too well that to put the NHS on a long-term sustainable footing will require even more radical reform to curb the trend of demand.

Focusing on improving immediate access and cutting waiting times, while vital for patients now, must not hinder efforts to shift resources from sickness to prevention and hospital to community. The ten-year plan will need to deftly work out how to marry recovery and reform simultaneously. The stakes have never been higher.

Kathy Mclean is chair of Derby and Derbyshire and Nottingham and Nottinghamshire ICBs.