What the new NHS operating framework must say

Integrated care systems (ICSs) hold huge potential. Performing at their very best they hold the potential to address the root causes of health inequalities and to help smooth the way for true partnership working between NHS and other key local and regional organisations to meet increasing levels of demand.

NHS England’s (NHSE) eagerly awaited new operating framework will be a crucial tool to help ensure ICSs receive the autonomy and resources they need to succeed. The question remains as to whether NHSE can reinvent itself and create the agility it needs to become an organisation that is arm’s length, but five factors will be crucial.

Subsidiarity

First, the new framework should be underpinned by the principle of subsidiarity with a clear justification for functions undertaken at national, regional or system level. NHSE national and regional teams as well as integrated care board leaders should recognise that successful and sustainable quality improvement can be driven by provider organisations developing local solutions that can then be scaled.

…healthcare leaders must be allowed the time and space they need to look out to the communities they serve and across systems

NHSE can support a paradigm shift away from external oversight and intervention and towards enabling and supporting improvement and it can also play a key role in sharing best practice. ICBs can do the same by facilitating and enabling – rather than managing – providers to collaborate, innovate and deliver care locally. To do this successfully, ICB leaders will also need to support and challenge each other and place greater emphasis on peer-to-peer support and sharing. As ICBs demonstrate their ability to act as system leaders, NHSE in turn will also need to review the role of regions and devolve capacity from the centre to local systems.

To truly remodel and improve care and put the health service on a more sustainable footing, healthcare leaders must be allowed the time and space they need to look out to the communities they serve and across systems – not only upwards to the centre of NHSE and government. ICS leaders have far-reaching duties to their communities and they will be charged with developing a multitude of stakeholder partnerships to meet these. Crucially, they must be allowed the freedom to do so.

As such the new operating framework should also include a commitment to focus on a small number of national priorities and some local outcomes, as well as clarify regulatory functions with a renewed emphasis on improvement, supportive facilitation and much more selective direct and proportionate intervention, which would see well performing systems being subject to less oversight and scrutiny.

Sustaining behaviour change

Second, at all levels, both within NHSE and across systems, there will need to be a commitment to sustaining behaviour change and the confidence to be brave in calling out unhelpful practice.

Healthcare leaders are becoming increasingly concerned that old habits die hard and that the behaviours demonstrated at various levels within the NHS hierarchy put at risk the very cross-system working and collaboration the reforms are trying the achieve.

Leaders dream of a world where system leaders are allowed to work together in streamlined and collaborative partnerships to support and improve local services

An area of particular concern is the lack of consistency in the approach of NHSE’s regional teams. This can vary from genuine partnerships of equals and practical improvement support to burdensome performance management which includes duplicative requests for information and attributing blame to individuals rather than addressing system issues in the round. Sir Chris Ham has likened this to a ‘parent/child’ relationship when what is needed is one of ‘adult to adult.’ Leaders dream of a world where system leaders are allowed to work together in streamlined and collaborative partnerships to support and improve local services.

As the recent Messenger Review of NHS leadership and management recently noted, the ‘institutional instinct… to look upwards to furnish the needs of the hierarchy’ can result in poor behavioural cultures within NHS organisations themselves. A more helpful approach would see NHSE redistributing its resources to strengthen the focus on delivering longer-term priorities. Our members tell us that continuous requests to bid for smaller pots of funding for specific projects often at short notice drives short-termist behaviour and leads to poor value for money.

These shifts will entail a huge organisational development programme including in the behaviours and cultures of NHSE’s national and regional workforce to one which supports rather than directs the changing healthcare system. This will naturally take time and sustained investment. Healthcare leaders should be involved in this work and high-quality research undertaken by Sir Gordon Messenger, Dr Claire Fuller and Sir Chris Ham provide a wealth of recommendations to be taken forward. Considerations should include how best to work with partners and use existing capacity and capability as well as strengthening the crucial relationship with local government.

Time to prove their worth

Third, in the interests of organisational stability both the government and the political opposition must recognise that major healthcare reforms need time to bed in and prove their worth, any additional significant policy alterations at a crucial moment of reinvention should be avoided.

The health service is already in the process of implementing a huge change, universally supported across the sector. Healthcare leaders now need the agency and the resources to get on with the job. Structural stability is needed to enable local reform.

Fourth, following the principle of mutual accountability, NHSE’s executive team, alongside its regional directors and ICS leaders, should all be signatories to the new framework.

Finally, there must a clear process of evaluation. System leaders are very keen to work with NHSE to do this and ensure we all know what good looks like when it comes to the new operating model. It is through collaboration and close working that we can truly begin to reset the conversation.

Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on Twitter @FRSAMatthew

This article was first published in HSJ on 12 October 2022.