A wind of change is blowing through NHS England. Last week’s announcement by Amanda Pritchard of the merger of NHS England, Health Education England and NHS Digital with effect from April 2023 was accompanied by a commitment to reduce staffing by at least 30 per cent and up to 40 per cent. The stated aims are for NHS England to become ‘a simpler and more integrated organisation’ and to create space for integrated care systems (ICSs) to lead at a local level.
These changes are welcome recognition that fragmentation in the national headquarters of the NHS combined with multiple and sometimes conflicting demands are incompatible with the ambitions set out for ICSs. Greater devolution of decision making and a focus on ‘an organization that can speak with a single voice’ are worthy aspirations and require all parts of the NHS to work differently. Fewer staff in the national headquarters and seven regions of NHS England and less siloed working are a first step in this process.
Equally important is rebuilding respect between leaders based on adult to adult rather than parent to child relationships alongside clarity about roles and responsibilities when performance goes off track. This requires an investment in relationship building and understanding that trust is the currency that will determine how ICSs will work in practice. It also means agreeing rules of engagement in which ICSs have the primary responsibility to intervene to address performance challenges in their areas.
Four other conditions must be met. First, national leadership is shared between NHS England and the Department of Health and Social Care creating a risk of mixed messages in the absence of aligned working. Increasing political oversight of the NHS as it deals with the backlogs built up during the pandemic and declining public satisfaction with the NHS accentuates this risk. The imminent update on the NHS long term plan will be an early test of whether clarity and consistency at the centre can be achieved.
Second, more effort needs to go into ensuring that ICSs have the capabilities needed now that they are statutory bodies. Unless they are able to recruit staff with the right mix of skills and experience to fulfil the expectations set for them, ICSs are being set up to fail. As system leaders, ICSs should be able to draw on all available talents among partner organisations and in regional offices as the role of the latter evolves.
Third, one of the most important safeguards against an overreaching centre is the opportunity for ICS leaders to work with local authorities in engaging people and communities. This depends on national leaders recognizing and valuing the contribution of local authorities in delivering the four purposes of ICSs. Last week’s announcement was silent on these issues, reinforcing concerns that ICPs will take second place to ICBs in the new arrangements.
Fourth, staff need to be treated with dignity and respect throughout the move to a new structure. The challenges of the pandemic have fallen heavily on NHS staff who have worked tirelessly to respond to the crisis and support recovery. To twin this with a reduction in staff numbers will be particularly painful for those involved. It is essential that the changes are undertaken transparently, and that staff at all levels are treated sensitively and supported throughout the transition to the new structure.
The new operating model for the NHS, being developed by NHS England, offers an opportunity for these and other issues to be addressed. Creating a smaller and more focused centre is – for now – a good direction to pursue but critical to handle carefully.