An integrated start

by Paul Brown

29 June 2022

New structures, which start this week, aim to deliver more joined-up care, with whole systems working together to optimise services and experience for patients. But success will also require changes in culture and attitude.

Friday 1 July 2022 is a momentous day for the NHS. It is the day that the way we work together across the NHS, completely changes. The boundaries and silos that we have all complained about for years, the purchaser-provider split, and the contractual disputes are all gone. We are no longer competing against each other within a local area, we are working together towards a common goal of improving the health and wellbeing of our populations.

We would like to think that that has always been the case. Patients have been at the centre of the NHS since it began in 1948. But the bureaucracy that has built up around it has not always supported us to work in the way that we would like to.

Now we have an opportunity to change that, as new integrated care boards (ICBs) are established in law, and we enter the era of system working. And this is not just about how care is commissioned, it does not just affect those who have previously worked in clinical commissioning groups. This change will impact how provision works, perhaps even more so than commissioning. It’s time to change that language too. We are working in collaborative systems. We are sharing risk. And we are thinking across pathways to deliver the care that our populations need.

Provider collaboratives will support organisations to work together to join up services across areas. In some places, decisions about service provision, budgets, and contracting may be devolved to groups of trusts, working together in this way. The separation of roles and responsibilities that we have been used to throughout most of our careers, will blur. Much of this joint working will happen at place level, making a real difference to communities and recognising assets beyond just those belonging to the NHS.

But the change of organisational structure will not make any difference unless we change as well. I chaired a roundtable last week where we discussed the challenges we faced in our systems to make this intended change a reality.

One of the things that struck me was how different ICBs will be, in terms of size and starting position. Some, like in Staffordshire and Stoke-on-Trent, are merging several CCGs to form the ICB. Others, such as Northamptonshire and Somerset, are a direct match with the former CCG so are experiencing less uncertainty around roles and structures. Some like Greater Manchester and North East and North Cumbria combine numerous places. But we all face the same challenge of working differently.

ICBs will have a much changed role to that of the predecessor CCGs. They need to model the collaborative working that we need across the system – working transparently with partners. Any ‘us and them’ attitude risks completely derailing the transformational changes that we want to make for our populations.

The system approach to managing financial resources, both revenue and capital, will require staff within ICBs to develop a range of new skills. The competencies developed through working in a commissioning body will continue to be valuable, but they will need to be built upon. Skills and knowledge around capital accounting will be required, for example, to support prioritisation across the local system.

Relationships will be key to success. In my conversations with other ICB chief finance officers, I have been reassured by the similarities in our ambitions and aims. We are all facing similar challenges and it will be important to share experience as ICBs develop. And this is true for finance staff at all levels.

The changes to our ways of working, while welcome, will sometimes be difficult and we will need our networks, through the HFMA, One NHS Finance, and local structures. We must not underestimate the cultural change that the Health and Care Act 2022 is asking us to make.

We often hear that the culture needs to change and, this time, it really does. Our relationships across the finance function will support us in that and will help us to lead the way in our organisations.

Friday 1 July 2022 is the beginning of a journey for the NHS. It could be an exciting one. It will certainly have ups and downs. But let’s make sure that it is an effective one that makes a real difference for the communities that we serve.