Bill sets right direction but concerns remain over central powers

Many of the changes are widely supported, removing obstacles to more collaborative working. However, the bill also includes more controversial clauses that would give ministers new powers to control the detail of how the service runs.

The bill was laid before Parliament on Tuesday and will build on the development of integrated care systems, which have already been working under partnership arrangements. In particular, it will see the establishment of statutory integrated care boards (ICBs) and statutory integrated care partnerships (ICPs).

Health and social care secretary Sajid Javid (pictured) said the legislation would help the NHS to meet demand, build a better health service and bust the backlog. ‘This will support our health and care services to be more integrated and innovative so the NHS can deliver for people in the decades to come,’ he added.

The bill seeks to reverse many of the reforms in the Health and Social Care Act 2012 and will move the service away from the competitive basis that was introduced under the internal market. All NHS organisations will have a new duty to pursue the triple aim, considering the impact of their decisions on the health and wellbeing of whole populations, the quality of care and the sustainable use of resources. And procurement of clinical services would be subject to less bureaucracy and a reduced need for competitive tendering.

The bill would also see the functions of the NHS Trust Development Authority and Monitor formally move to NHS England. And changes would be made to the financial framework.

The national tariff would be replaced with a new NHS payment scheme, setting rules for how commissioners establish prices to pay providers for healthcare services. NHS England and NHS Improvement have already published proposals to move to a default system of aligned payments and incentives, based on a fixed price for agreed activity plus a variable element, initially to support additional elective activity as part of the recovery agenda.

Capital spending limits would also be introduced for foundation trusts to address concerns that a foundation trust could decide to invest its own cash to invest in capital without considering the overall impact on the local system ICB capital envelope, which could have implications for the overall national capital expenditure limit. However capital limits would be set on an individual basis for a named trust for a year and only used where other forms of resolution had been unsuccessful.

According to the explanatory notes issued alongside the bill: ‘In recognition of the expanded powers and responsibilities of NHS England, the bill seeks to introduce an additional accountability mechanism to support the Secretary of State in their democratic oversight of NHS England.’

The powers are not intended to be used frequently to intervene in the affairs of NHS England. ‘NHS England will remain an arm’s length body and will therefore continue to exercise the majority of its functions as it does now,’ the explanatory document said. ‘The mandate will remain the primary mechanism through which the Secretary of State will set out the priorities that NHS England should be seeking to achieve.’

The bill would also give the health secretary the power to call-in a proposed local reconfiguration at any stage of the process, replacing the current system of local authorities referring cases for decisions to be made.

According to Simon Stevens, NHS chief executive, the proposals for integrated care were widely supported and built on the ‘sensible and practical changes’ already underway across the NHS. ‘They go with the grain of what our staff and patients can see is needed, by removing outdated and bureaucratic legal barriers to joined-up working between GPs, hospitals, and community services,’ he said. ‘And by enabling mutual support between different parts of the local health and care services, they will undoubtedly both help tackle health inequalities and speed the recovery of care disrupted by the covid pandemic.’

Nigel Edwards, chief executive of the Nuffield Trust, agreed there was a ‘clear logic’ to parts of the bill, allowing for more collaboration. But he added that it was ‘unfortunate’ that these changes were bundled up with new powers for politicians to dictate the detail of how the health service runs.

‘Politicians should have the power to tell the NHS what to do, but they are not best placed to tell it exactly how to do it,’ he said. ‘The new role for the Secretary of State in intervening at any stage of changes to any service is a recipe for local decisions ending up in Whitehall and Westminster. It risks gridlock and a lack of innovation and ministers themselves might come to feel it as a millstone around their necks.

NHS Confederation chief executive Matthew Taylor (pictured) also raised concerns. While the bill offered the right direction of travel, albeit with a tight timetable, some of the proposals were not welcome. In particular he highlighted ‘those that could lead to significant centralised and ministerial involvement’ in everyday matters that affect the NHS. ‘In their current form, these plans also bring with them the risk that arm’s-length bodies, including NHS England and NHS Improvement, could be split up or abolished without any real scrutiny,’ he said.

NHS Providers chief executive Chris Hopson raised similar concerns. ‘There is no suggestion here that a publicly funded service like the NHS should not be held to account,’ he said. ‘Rather, that the strategic direction is the domain of politicians, who should then allow NHS leaders in operational and clinical roles – with day-to-day responsibility for supporting patient care – the space to deliver those strategic objectives without undue political pressure or interference.’

The HFMA has produced a summary of the bill. You can read it here