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The NHS Long Term Plan: Governance for integration

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By Hamza Drabu & Anne Crofts


Published 30 January 2019


The word ‘governance’ appears four times in the NHS Long term plan (LTP); three times in relation to innovation, technology and data and once in the context of the new NHSI/NHSE operating model, where there is a reference to delivering system governance and accountability mechanisms to ensure the NHS as a whole secures best value from its resources.

How the objectives of the LTP will affect the governance structures of existing NHS providers is not examined. Boards of NHS Trusts however, will no doubt be anxious to understand what the implications are for the sustainability and long-term viability of their individual organisations. Particularly as the funding focus (once the provider deficit is paid down) is in developing primary care and community services.

Many of the current issues facing NHS Trusts - workforce gaps, lack of infrastructure investment and maintenance, inability of social care to relieve pressures on the NHS - are not directly addressed in the LTP although the anticipated workforce plan and green paper on Social Care, coupled with the Spending Review, will presumably start to cast further light. Given the difficulties of the “day job” it is perhaps not surprising that many NHS Trusts are anxious to ensure from a governance perspective, that membership of an STP, and in due course a “more evolved” Integrated Care System (ICS), will not create more risk to their organisation’s ability to provide safe care to patients.

Governance structures

From a legal perspective, the governance and accountability structures of the STP/ICS have been somewhat opaque. It has not been obvious, other than by financial incentives, how the STP/ICS are able to direct changes to organisational priorities and duties, in order to deliver new integrated models of care within the existing legislative framework. Those of us who have worked over the last 5-10 years supporting Pilots/Vanguards/ACPs/ACO/ICPs are only too aware of how long it can take to put in place contractual and governance structures: these structures must enable all the different players in the integrated care model, (acute, primary care, community care, voluntary sector, mental health, social care) to come together to plan and deliver care that surmounts organisational boundaries, and puts the patient at the centre. At the same time, these plans need to ensure that the Boards of the relevant organisations are fulfilling their primary statutory functions and can assure themselves of the quality of care delivered to their patients for which they remain responsible.

Integration remains the focus of the LTP but there are no proposals for big structural changes; the STPs/ICSs won’t have statutory status and although there is mention of a possible new NHS Integrated Care Trust, by and large the proposed changes in primary legislation aim to give effect to the Plan and build on the existing framework and are not radical. The timetable for amendments is not addressed, however, it is not unreasonable to suppose that this could be at least 18 months.


Assuming the proposals are adopted, CCGs and NHS providers are to have new statutory duties to promote the “triple aim” of better health for everyone, better care for all patients and sustainability, both for their local NHS system and for the wider NHS. Presumably the aim of such duties will be to strengthen the chain of accountability, such that the whole system is at least the sum of the parts. However, in a framework that still retains autonomous providers there is likely to remain a tension between what is in the best interests of an organisation and its patients, and what is in the best interests of the wider system and the whole population. There will be devil in the detail to come as to how accountability for fulfilling the new duties would actually work and how such tension would be reconciled.

The suggestion that ICSs could operate more effectively if CCGs and Trusts are able to exercise their functions jointly is particularly interesting for FTs. Currently, FTs cannot make decisions in joint committees; it is a fundamental principle of FT autonomy that an FT’s functions cannot be delegated to any committee other than of its own Board Members. To date this has meant that any decision of a “Partner Board”, of which an FT is a member, effectively requires unanimity in order to bind the FT. A relaxation of this rule will therefore have quite far reaching consequences as FTs may potentially be “outvoted” and will need to pay particular attention to how governance and voting rights in any such committee are exercised.

Competition and patient choice

Other proposed legislative changes include removing the “counterproductive” effect that general competition rules and powers can have on integration in the NHS. Such as removing the Competition and Market Authority’s (CMA) duties in relation to NHS mergers, pricing and NHS provider licence condition decisions, as well as Monitor’s competition role. This might indeed simplify competition issues relating to acquisitions and mergers, not just of whole organisations, but mergers of functions as well (for example pathology services), enabling control of whole or part of an organisation to be more easily ceded to another.

Of course, the flip side to relaxing the competition regime is the potential impact on patient choice which the competition regime serves to protect. In a similar vein, the recommendation is to “cut the delays and costs” of commissioners having to go through procurement processes. There is no doubt that the transparency and equal treatment requirements of the EU procurement regime, generating as they do outright “winners and losers”, can put incredible strain on fragile health economies. However, the absence of competition can also have undesirable consequences, particularly where this means inefficient monopolies subsist. This might be mitigated to a degree by robust contract management, but the plan also points to £700m savings in administration costs, suggesting that upskilling in this area may not be a priority.