How Soon is Now? Delivering change at pace through the ICB Blueprint

The circulation of the Model Integrated Care Board Blueprint last week offers an extremely valuable insight to the direction of the NHS and its new ways of working, both in a systems sense but also a cultural one. This is an internal NHS document demonstrating the new style of central direction under the Mackey leadership. The detail reinforces previous indications of what to expect from the 10-Year Health Plan in June but also emphasises the major cultural shift required of NHS leaders, and all of us involved – focused on pace of change and urgency to deliver.  

A new NHS architecture under Mackey 

The best way to predict Mackey’s moves is to consider his career to date: an integrated Foundation Trust running hospitals, community services, GP services, care homes backed up by extensive sub-cos and formation of a £2bn income provider collaborative. His vision is best represented by the Northumberland Accountable Care Organisation (ACO) developed but abandoned within the Vanguard programme of 10 years ago.  

The new NHS design is increasingly clear: a new streamlined Centre, Regions, 25 or so modified Integrated Care Boards (ICBs) and then a local NHS led by large provider collaboratives groups possibly formalised as a type of ACO. These new integrated providers will essentially run the NHS delivering services and sub-contracting as commissioners. If you can hear a noise now, then that may be the Shelford Group laughing.  

All eyes on Neighbourhoods 

While still apparently nebulous, we’ve seen far more progress in the early Neighbourhood model adopter sites than is appreciated. Signalled for three years, this is the pivotal element of the new NHS and must work in order to deliver the Government’s three shifts – but how? It means bringing together the Cinderella services and all the disparate, fragmented, out of hospital services with complex decision space around the Voluntary Community and Social Enterprise sector. We’ve left this challenge aside for decades but the success of Labour’s plans depend on it. 

Let’s see what is mandated in the 10-Year Health Plan on Neighbourhoods, especially levers that encourage hospitals to shift services and resource. The substance of the new Neighbourhood Health Centres will be key here but the central question around Neighbourhoods is not “why”, or even “what”, but “how” – how do we get from fragmented local services, estate, IT and workforce to the end goal?  

Where do decision-making and commissioning sit? 

We have to move decision-making closer to the point of delivery. The new approach to medicines optimisation is clearly aimed at doing so, linking the hand that writes the script to the resource consequences. Prescribing and Continuing Healthcare are both being placed closer to the provider NHS, no doubt as both feature as financial problem children of all ICBs. It will be interesting to see how material procurement is played out in a new world of local determination and accountability. Things are ominously quiet around NHS Supply Chain, at least for now.  

It will be interesting to see two main things: any mandated actions for the new lead provider groups around resource shifts and any options for radical models in the imminent GP Contract. Regardless, expect major variation in the local Neighbourhood models, some of which will be planned and reflecting population health needs but some of which will be formed through parochial compromises.  

We will have larger, more strategic ICBs with a chance to actually do some commissioning.. It is great to see health economics mentioned but how can ICBs strategically commission with Public Health in separate bodies, with separate funding? And where is the science, methodology, expertise, data and workforce to do this? Commissioning has failed to thrive through attempts like PBMA and then World Class Commissioning. Instead, we got stuck in transactional contracting, gaming, competition and throwing snails into each other’s gardens.   

Operating challenges within this new system 

There is a massive challenge for everyone within the NHS, with the brave and better-resourced seizing the inherent opportunities. Variation will increase in all kinds of ways and that is deliberate as well as inevitable given the continuation of the weighted capitation funding models. And that variation will be broader in scope given the push for “end to end pathways”, enabled by devolution of specialised services.  

The challenge for those working with the NHS – including industry, digital and medtech – is perhaps even greater as they have largely failed to predict what is happening and are quickly trying to get to grips with this new world – clinging to redundant paradigms and often viewing the NHS from their singular perspective. The only way to truly understand the NHS is to view it from the inside out, and the Blueprint is a great aid to that.