System proposals revealed

Finances will increasingly be organised at the ICS level with allocative decisions placed in the hands of local leaders, according to proposals tabled at yesterday’s NHS England and NHS Improvement board meeting in common. ICSs would be the key bodies for financial accountability and financial governance.

A single budget pot would be created for each ICS, bringing together CCG commissioning budgets, primary care funding, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally held transformation funding that is allocated to systems. ICS leaders would distribute resources according to national rules – for example, for mental health investment – and to support locally agreed priorities.

Significant resources would be delegated to place level, including primary care practices and community services.

The paper reiterated the long-term plan commitment to rolling out blended payments for secondary care services and it said each ICS must agree and codify how financial risk will be managed across places and between provider collaboratives. The changes should reduce administrative and transactional costs, it added.

The capital regime introduced over the last two financial years will be embedded further, with ICSs responsible for allocating capital envelopes. More details of ICS financial duties will be included in the 2021/22 planning guidance.

Commissioning functions normally carried out by CCGs need to become more strategic with a clear focus on population health outcomes, the paper said. Commissioning will change in three ways:

• There will be system-wide strategic commissioning
• Systems will take a new approach to service transformation and pathway redesign
• There will be an opportunity to use analytical skills to better understand how best to use resources to improve outcomes, rather than contract management, due to the greater focus on population health and outcomes, and shared system ownership of financial envelopes.

The paper outlined two options for statutory models – a joint committee, with one CCG per ICS, that binds together existing statutory organisations, or a separate legal body, created partly by repurposing CCGs, that would take on their statutory functions, including commissioning. NHS England and NHS Improvement prefer the latter option, though it accepted either approach would allow systems to reshape their operations and deliver patient care and outcomes support at place level. The national bodies would make a continued employment promise to staff involved in commissioning functions, as CCG responsibilities move into new bodies.

Consultation on the proposals ends on 8 January.

NHS Providers chief executive Chris Hopson (pictured) said the proposals marked a step change in the evolution of system working, though greater detail was needed.

He added: ‘We welcome the proposed shift to strategic commissioning and away from transactional contracting, as well as the clear emphasis on the pivotal role of trusts, and other providers, as leaders and co-leaders of collaborative arrangements at neighbourhood, place and system level.

‘Trust leaders tell us that 80% of care is delivered locally where people live, so it is right to position place as the key building block for integrated care in partnership with local government and others. This emphasis on providers and place and the avoidance of creating ICSs as new style, all powerful, strategic health authorities, provides a sensible and pragmatic approach to the next stage of development of system working that we welcome.’

NHS Clinical Commissioners chief executive Lou Patten said CCGs had been successful in developing the partnership between clinicians, managers and lay members. ‘While recognising that the majority of commissioning functions will continue at ICS level in what is being proposed, the great work at neighbourhood and place, enhanced by the focus on the pandemic must continue. The local stewardship role of CCGs and their joint working with local authorities must not be lost – we cannot throw the baby out with the bathwater.

‘There is a huge amount of organisational memory within CCGs, and it is positive that there is a continued employment promise within these plans to ensure staff are retained to continue the current and future commissioning responsibilities,’ she added.