NHS reform: Language has changed, objectives remain the same

The cycle of health system reorganisation seen over recent decades has accelerated under Keir Starmer’s Labour government, marked by the scrapping of NHS England, major reductions in system levers, and a fundamental remodelling of integrated care board (ICB) purposes. But, as stakeholders at the Forum noted, the more things change, the more they stay the same. The key for health conferences such as this, is to analyse how the delivery of integrated care will change.

Naomi Eisenstadt argued that there remains a lack of a shared understanding of what integration is fundamentally. She largely welcomed the strategic direction outlined in the ICB Model Blueprint last week, with its focus on population health, health inequality and the important role of ICBs in managing contracts with providers and determining the flow of resources. However, further clarification as to the role of neighbourhood teams is needed and further emphasis on the 4th aim of ICSs (social and economic development) would be welcome.

Professor Patrick Vernon, Chair of Birmingham and Solihull ICB, acknowledged the “mixed” impact of ICBs so far, but stressed that significant work had been done to break down silos in the Birmingham and Solihull area. Vernon also pointed out that many of the actions outlined in the model framework are already being delivered through practical ICS working. But with providers facing persistent resource constraints and ICBs set to merge into even larger footprints, progress is likely to remain uneven.

Enhancing the role of strategic commissioning

Strategic commissioning, now at the heart of ICSs’ role as outlined in last week’s model ICB blueprint, will define how these systems operate going forward. But do we fully understand what’s being asked? And how is this different to previous approaches to commissioning? Eisenstadt, Chair of Northamptonshire ICB and Non-Executive Director at the Department of Health and Department for Education, spoke about the enduring challenges of collaboration and silo breaking.

There’s still a lingering mindset in parts of the system that “if only there were more of me, then everything would be alright,” she noted, perhaps a symptom of fragmented culture, not a lack of strategy. “I think we forget why the silos persist,” reflected Eisenstadt, “they remain because vertical accountability is far less complicated than an integrated approach.”

Danielle Oum, Chair of Coventry and Warwickshire ICB was keen to highlight the opportunities of ICBs having more streamlined priorities and a greater focus on strategic commissioning: “What this means now is that we can accelerate the pace of change,” Oum reflected.

She continued: “The blueprint helps set out how ICBs will the shift from transactional and operational oversight, with a focus on performance management, towards a far more strategic and informed approach to commissioning, using their purchasing powers and their role as contract holders to drive improvement across population health.”

Speaking on the same panel, Victoria Underhill, Director of Integrated Care for Optum, noted the subtle differences between strategic commissioning and previous approaches: “I think strategic Commissioning puts population health management at the heart of strategy…ICBs have a critical role as strategic commissioners that will enable neighbourhood working, whether that’s through creating the sort of right conditions through technology enablers, data sharing, financial flows, commissioning across a pathway or for a population.”

Clear from the day’s discussion was that the best integration still happens on the frontline, when different teams are given the means to collaborate effectively together to deliver care.

Reform fatigue

Christine O’Connor reminded attendees of a hard truth: “Reorganisations do not improve the delivery at the point of care and are often disruptive to it.” Despite the promise of structural reform, what matters to frontline staff and service users is whether delivery actually improves.

ICSs were established to enable a more integrated approach to commissioning and delivering services. Yet meaningful engagement with key system partners remains inconsistent.

Nowhere is this clearer than in social care. The conference took place in the context of yet more deflating news for the sector. Nadra Ahmed, Chair of the National Care Association, powerfully highlighted the ongoing marginalisation of social care. “We put £68 billion into the economy with a 1.7 million-strong workforce, but we cannot get a seat at the decision-making table, locally or nationally.”

David Morris, PwC’s UK Central Market Head, bluntly summarised the disconnect between rhetoric and reality regarding integration: “We have a long way to go before integrating properly.”

Cllr David Fothergill, Deputy Chair of the Local Government Association, was keen to point out that, while we are in the middle a significant period of reform for the health sector, local government is going through a once in a generation period of change following the Devolution White Paper last year. “There are 317 councils across England, about 170 of those are awaiting reorganisation,” Fothergill continued. “We recognise the scale and urgency of the challenges currently facing health services, but we must not miss the opportunity to rewire change together. Integration and joint work in a system, place and neighbourhood is vital if we are to design and deliver services that put citizens at the heart of everything.”

Optimising financial flow to unlock transformation

Financial flows will be key to enabling this new approach to commissioning and to empowering providers to transform services on the ground. Andrew Moore, Joint Chair of University Hospitals of Northamptonshire NHS Group and University Hospitals of Leicester NHS Trust, highlighted the contrast with the retail sector, where financial and workforce control mechanisms are far stronger. In health and care, however, over-reliance on agency staffing and weak grip on costs make transformation harder to deliver.

Technology remains an underused lever. Alex Crossley, Director of Transformation and Finance at NHS England, called for deeper partnerships with industry and smarter use of tech to overcome persistent productivity challenges. Strategic commissioning must include strategic deployment of digital tools.

A familiar destination despite the new language

There is a risk that ‘strategic commissioning’ turns out to be just commissioning with the word “strategic” tacked on. Policy leaders have a remarkable ability to rename old ideas and repackage them as innovations.

This tendency can frustrate frontline professionals and system leaders alike. Yet, as PPP Chair Stephen Dorrell noted in his closing remarks, it also suggests consistency in the direction of travel that should be built upon. The structures and language may change, but the core goals of integration, prevention, and efficiency remain. The challenge, as ever, is in finally delivering them.

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You can read select insights from the Integrated Care Delivery Forum Medicines and Care Pathways Theatre here.

For more information on the Integrated Care Delivery Forum, please write to david.duffy@pppinsight.com.