Integration proposals supported by the HFMA

Last year, NHS England and NHS Improvement set out proposals for the development of ICSs. In its response, the association said many of the issues facing system partnerships are a result of the fact that they lack statutory powers and accountability, while trying to allocate resources to and monitor the performance of statutory organisations.

Systems needed a single lead organisation placed on a statutory basis. The proposals would deliver this, and promote value for money in the use of resources, the association said.

‘It will provide a clear central path of vertical and horizontal communication and accountability between organisational, place-based, regional and national plans,’ the HFMA response said.

‘This will enable managers to focus on the best provision of health and social care that achieves maximum value from available resources, rather than having to consider how these decisions can be made within a statutory framework that does not support collaboration and joint working.’

The simplification of the finance regime during 2020 in response to the Covid-19 pandemic had removed many of the barriers to collaboration, the association said. An earlier HFMA briefing, The future NHS financial regime in England: recommendations, proposed a number of developments to support system working.

The association added that it was important that smaller parts of the system had freedom to have bespoke local services at primary care network or place level, and it would be helpful if broad expectations for each level (PCN, place, ICS and region) were set out.

It was important to retain clarity and transparency in the way funding is allocated from the centre to ICSs, and in resource allocation and contracting between ICSs and providers. Where resources do not meet demand, funding priorities – together with the rationale used to set them – must be clear. Financial performance management should reflect this, the HFMA added.

Under the planned legislation, ICSs would be able to focus on overall system strategy, population health management, and providing clear frameworks to allow providers to focus on delivery. But the HFMA said several key components must be in place to achieve this. These included fair funding allocation that reduces waste; consistent system performance oversight; support for place-based organisations and provider alliances; clarity on NHS and local government roles; and governance arrangements that give representation to all organisations, patients and the public.

The proposals outlined two options for ICS structure – option 1 would put in place a statutory committee, with an accountable officer, to bind together current statutory organisations; option 2 would establish a statutory NHS body that would bring some clinical commissioning group functions into ICSs.

On balance, the HFMA preferred option 2, though it acknowledged this structure could lead to disruption in the short term. Also, while this model could feel like a constraint where systems are already collaborating well, others could use the statutory footing to build on current partnership working. But there was a danger in some less mature systems that the new organisation would see itself as ‘in charge’ and try to impose its will rather than nurturing collaboration.

Collective working must be the foundation of ICSs, whichever model is introduced, the association said.

It raised some concerns on the ICS role in working with local authorities and addressing public health issues. ICSs will take on CCG functions, but the HFMA said this must be more than simply a transfer of functions if the social determinants of disease are to be tackled and care integration is to be optimised.

In general, the HFMA also backed proposals to transfer or delegate NHS England commissioning decisions to ICSs, where appropriate. Transferring these responsibilities had the advantage of simplifying the resource management process and would represent a step towards population budgets. However, such a move would require legislation, and some services, such as ambulance provision, should continue to be commissioned at pan regional or national level.