Photo: Scaffold from Erich Ferdinand flickr photo stream

On 1st July 2022 Integrated Care Boards (ICBs) took over commissioning responsibility for the NHS. This followed the Health and Social Care Act receiving Royal Assent at the end of April and passing in to law.  Integrated Care Boards are part of the new Integrated Care System laid out in the 2022 Act and, along with the Integrated Care Partnership (ICP), will have statutory status and will collectively hold the ICS’s legal powers and responsibilities. There are 42 Integrated Care Boards across the country and many held their initial meeting first thing in the morning on Friday 1st. These boards have a statutory footing and will be responsible for commissioning most health services in the area they cover.

What does this mean? It means that Clinical Commissioning Groups will be absorbed into their local ICSs; and their commissioning powers and most of their staff will become part of the ICS body. This will halt enforced competition (which has been criticised as overly bureaucratic and fragmenting of services). Section 75 of the Health and Social Care Act will be repealed and replaced with a new system, the Provider Selection Regime (which will give NHS bodies a wider range of options when commissioning services).

In July 2021 the British Medical Association expressed its concerns and demands regarding the 2022 Act.  For many this was too little too late.  The BMA were warned about the direction of travel the government were taking following the 2012 NHS reforms in the Health and Social Care Act, as Ewen Speed noted in the time in his 2012 blog post , and Caroline Molloy reiterated more recently, but it wasn’t until the new Bill was released in 2021 that they decided to take a stand.  Their concerns addressed five areas.

Firstly, they called for increased government accountability for ensuring the health and care system has adequate numbers of staff to meet patient need, now and into the future, by requiring the secretary of state to produce accurate and transparent workforce assessments to directly inform recruitment needs. This concern, echoed by the Royal College of Nursing and over 100 other health and social care organisations, has already been realised.  In April MPs rejected an amendment to the bill which would mandate transparency on the workforce by requiring the government to provide regular independent reports on the number of people working within the NHS across the country. At  a time when many areas are already very overstretched with staff shortages amongst clinical and allied staff, it is not clear how (or if) the government will ensure that the workforce is maintained at a level sufficient to meet the needs of the population and ensure patient safety.

Secondly, they called for clinical leadership to be at the heart of the new Health and Social Care System by embedding clinical leadership and patient representation at every level of ICSs, including formalised roles for local medical committees, local negotiating committees and public health doctors. Again this call was echoed by various groups representing primary, secondary and allied care.  GP leaders have warned that the requirement that only one GP be appointed to each board will mean that ‘vital expertise’ of GPs will be lost from this process.  Under the Act ICBs are required to have a primary care representative, a clinical director and a nursing director but there is no requirement for any further clinical representations on the boards and each board can decide for itself who their other members are.

Thirdly, they called for the NHS to be established as the default option for providing NHS contracts to truly protect the NHS from costly procurement and fragmentation of services. Alex Scott-Samuel suggests that this fragmentation of services could result in services being rationed and access to care becoming a postcode lottery.  Writing in the Times, Sian Norris, points out that there is no Parliamentary process to ensure allocation of services across the Integrated Care Boards. Whilst there is an expectation that GP registration will remain the key to Integrated Care Boards responsibility, this is only an expectation and not a requirement. It is up to NHS England, not parliament, to decide who each ICB will be responsible for. Without clarification, it has been argued that ICBs might be able to challenge allocations and thereby in effect to select patients. New groups of people could be excluded from NHS care, as certain migrant people currently are. Furthermore, the 2012 Act contained a clause that if an individual needed emergency treatment when outside their CCG area – perhaps while on holiday in a different part of the country – then they could access that treatment. No such clause is included in the 2022 Act. This could mean that an ICB will not be required to arrange provision of emergency services for a person outside its responsibility, but who happened to get ill or injured in the wrong place at the wrong time.

Fourthly, they called for the Act to rule out private providers wielding influence over commissioning decisions by sitting as members of NHS decision-making bodies. What the Act actually does though is remove existing competition rules and formalise Integrated Care Systems (ICSs) as commissioners of local NHS services through the ICBs. And the ICBs will in turn be able to delegate their own functions to provider collaboratives, including budget decisions. According to many acute trust chiefs, it is these provider collaboratives and groups, and not ICBs, that will wield the greatest influence; and these provider collaboratives are not directly accountable to the public or to the government.  This makes it even easier for the NHS to act a brand or kitemark for private providers as Alison Pollock and David Price warned back in 2011, with services provided by private provider for profit under the NHS badge, paid for by taxpayers with profits going to shareholders rather than back in to the system.

Finally they called for the Act to ensure safeguards and limitations over the secretary of state’s powers within the Bill to avoid unnecessary political influence in NHS decision-making. Again the concerns of the BMA in relation to political influence have been realised and the Act grants the health secretary authority over the health service. The powers of the secretary of state will actually be increased: to direct the NHS, create new NHS trusts, intervene in local service reconfiguration, and amend or abolish arm’s length bodies. S/he will have to publish a five-yearly report on workforce planning rather than the 2 yearly report that health care bodies called for.

While the BMA reported some minor successes, their document noted, unsurprisingly, that ‘the government ultimately failed to act on the concerns of frontline staff to address the main problems facing the NHS and our members: too few resources and, crucially, a huge shortfall of staff.  There is no longer anything but a token attempt by the current government to hide the political ambition to undermine and replace the NHS with an alternative far more oriented to private or for-profit providers. They are for regression in healthcare, against progression. We are losing our NHS, which is becoming a mere brand name. We are losing our right to local care and potentially some groups will lose their ‘right’ to any care. The 2022 Act has opened the door further and the ICBs are the latest step in the fragmentation of the universal, state funded, health care system as envisioned by Beveridge. Check who owns ‘your’ local GP practice. It could well be an American private equity company based in a tax haven!