To:

CCG accountable officers
ICS and STP leaders
NHS trust and NHS foundation trust chief executives

Dear Colleague

Integrated care systems: next steps

The whole country is rightly proud of the way the NHS has responded so swiftly and magnificently to coronavirus, the biggest public health emergency in its history, from the rapid implementation of innovative solutions to provide care for our most vulnerable communities to the impressive vaccine rollout.

Throughout the pandemic, the innovation of local leadership and hardworking staff has allowed us to accelerate the real progress made in breaking down barriers to integrated care in the way our patients and communities clearly need.

As you know, last November, NHS England and NHS Improvement invited views on strengthened proposals to put integrated care systems (ICSs), on a statutory footing.

We received thousands of responses from every part of the health and care system as well as the public. I am writing to update you on a few next steps and how we will take your responses forward.

The legislative proposals go with the grain of what patients and staff across the health service all want to see – more joined-up care, less legal bureaucracy and a sharper focus on prevention, inequality and social care.

It builds on the past seven years of practical experience and experimentation across the health service kicked off by the NHS Five Year Forward View, and the NHS Long Term Plan and reinforced by the flexibility NHS staff and organisations have shown throughout the pandemic.

The proposals are designed to be flexible, allowing the health and care system to continue to evolve, and are designed to better equip the NHS and local health services to meet the longer-term health and societal challenges over the coming years.

Our legislative recommendations to Government and Parliament

Your responses to our November paper have directly informed our recommendations to government and parliament and the recommendations below will form the basis of the government’s white paper.

We are publishing Legislating for integrated care systems, which sets the five recommendations we are making, alongside principles to guide how the government progresses this work.

The recommendations are:

1. The government should set out at the earliest opportunity how it intends to progress the NHS’s own proposals for legislative change.
2. ICSs should be put on a clear statutory footing, but with minimum national legislative provision and prescription, and maximum local operational flexibility. Legislation should not dictate place-based arrangements.
3. The NHS ICS statutory body should be supported by a wider statutory health and care stakeholder partnership. Explicit provision should also be made for requirements about transparency.
4. There should be maximum local flexibility as to how the ICS health and care stakeholder partnership is constituted, for example using existing arrangements such as existing ICS partnership boards or health and wellbeing boards where these work well. The composition of the board of the NHS ICS statutory body itself must however be sufficiently streamlined to support effective decision-making. It must be able to take account of local circumstances as well as statutory national guidance. Legislation should be broadly permissive, mandating only that the members of the NHS ICS Board must include a chair and CEO and as a minimum also draw representation from (i) NHS trusts and Foundation Trusts, (ii) general practice, and (iii) a local authority. As with CCGs now, NHS England and Improvement would approve ICS constitutions in line with national statutory guidance.
5. Provisions should enable the transfer of responsibility for primary medical, dental, ophthalmic and community pharmacy services by NHS England to the NHS ICS statutory body. Provision should also enable the transfer or delegation by NHS England of appropriate specialised and public health services we currently commission. And at the same time, NHS England should also retain the ability to specify national standards or requirements for NHS ICSs in relation to any of these existing direct commissioning functions.

Publication of government white paper

Based on our legislative proposals, the Department of Health and Social Care is today setting out new proposals to streamline and update the legal framework for health and care. Key measures included in the ‘Integration and innovation: working together to improve health and social care for all’ white Paper include:

• Support for our proposal to create statutory integrated care systems (as set out above).
• Support for our proposal to scrap mandatory competitive procurements by which NHS staff currently waste a significant amount of time on unnecessary tendering processes for healthcare services. Under today’s proposals, the NHS will only need to tender services when the NHS itself considered this has the potential to lead to better outcomes for patients. The Competition Market Authority will no longer be involved in NHS oversight. Local NHS services will have more power to act in the best interests of their communities.
• The safety of patients is at the heart of NHS services. The upcoming bill will put the Healthcare Safety Investigations Branch permanently into law as a statutory body so it can continue to reduce risk and improve safety. The Healthcare Safety Investigations Branch already investigates when things go wrong, so that mistakes can be learned from, and this strengthens its legal footing.
• Support for our proposal to formally fold Monitor and the Trust Development Authority (i.e. NHS Improvement) into NHS England.
• A package of measures to deliver on specific needs in the social care sector. This will improve oversight and accountability in the delivery of services through new assurance and data sharing measures in social care, update the legal framework to enable person-centred models of hospital discharge, and improve powers for the Secretary of State to directly make payments to adult social care providers where required.
• The pandemic has shown the impact of inequalities on public health outcomes and the need for government to act to help level up health across the country. Legislation will help to support the introduction of new requirements about calorie labelling on food and drink packaging and the advertising of junk food before the 9pm watershed.

Supporting staff through the transition

We have proposed that the NHS ICS statutory body will take on the commissioning functions that currently reside with clinical commissioning groups (CCGs) alongside some of the responsibilities that currently reside with NHS England. If these proposals are passed by Parliament, this will of course impact our staff, so we need to ensure the implementation is right.

Under these proposals we need to ensure that we support our staff during organisational change by minimising uncertainty and limiting employment changes as much as possible. We are therefore seeking to provide as much stability of employment as possible so that ICSs can use the skills, experience and expertise of our NHS people.

To make the transition process as smooth as possible for you teams we will introduce an ‘employment commitment’ for colleagues within the wider health and care system (below board level) affected directly by these legislative proposals including where relevant CCGs, NHS England and NHS Improvement and NHS providers.

Further information can be found in the FAQs on how we will support our people, give confidence over future employment arrangements and ensure that we can keep our collective focus on the recovery and transformation challenges that lie ahead which will be regularly updated.

Consultation on updates to the procurement regime

A common theme within the responses to the November paper was the frustration faced by your teams due to general competition rules and powers. To address these concerns we are also publishing The Provider Selection Regime, a new approach to procurement of services, to make it easier to develop stable collaborations and to reduce some of the cost burden associated with the current regime.

We have heard that you want a decision-making process that makes space for real collaboration to happen. The creation of statutory ICSs brings the opportunity to create a way of making decisions about healthcare services that is in step with the integrated, collaborative approach we have developed in recent years.

Supporting your teams with the guidance they need

Removing legislative barriers to integrated care is important but it is only one part of how we embed and take forward how our services are planned and delivered.

Throughout our engagement, you have reaffirmed your support for the idea that collaboration is more effective than competition in tackling the health and care challenges we face. In several important areas, we will share more detail and take specific action to fully realise this vision.

The experience of systems will inform planning guidance that we expect to provide in April 2021 and the future ambition for systems from April 2022. The Integrating care paper was not the beginning of our engagement and it will not be the end.

We will give all systems the chance to directly shape this and the other guidance and advice that they need during 2021.

The changes set out today will help to shape our future work, which at its heart is about enabling everyone we serve to live a healthier and happier life for longer, with more convenient, responsive services when people need them.

I look forward to working with you all on further developing and implementing integrated care systems.

Your sincerely

Amanda Pritchard
Chief Operating Officer, NHS England and NHS Improvement and Chief Executive, NHS Improvement