Health and Care Bill 2021 - initial key questions for systems

Published 14 July 2021

It’s been a long time coming, and there have been some twists and turns along the way, but the Health and Care Bill 2021 has finally been introduced to Parliament.  We now know the government’s vision, informed by extensive engagement with the NHS, of what a statutory ICS should look like.  But this is not a done deal.  We know that there are discussions within government as to whether aspects of the Bill should be amended, never mind the amendments which may be made as it makes its way through Parliament.  The delegated powers memo which was published alongside the Bill also refers to 138 powers within the Bill which allow for the making of delegated legislation, directions, guidance or schemes.  The devil may be in the detail!

At the same time, existing ICSs are faced with the challenge of preparing themselves for the arrangements that are scheduled to take effect in April 2022.  With the continuing management of COVID, the very welcome summer break and the prospect of another tough winter, time is short for systems to grapple with some pretty big issues if they are to hit the ground running next spring.  Therefore, even though the Bill may be something of a moving target, in our view systems should act sooner rather than later to address some of the key points which we in DAC Beachcroft’s healthcare team have identified below. 

Taking stock of existing arrangements

The Bill is intended to better facilitate existing and future plans for integration than is possible under the current legal framework.  Establishing the new structures should not therefore be a distraction from the service change that will bring benefits to patients and communities.

• How do the existing arrangements within your system compare with those outlined in the Bill and what may need to change over the coming months?
• How can disruption to existing arrangements and relationships which are creating value be minimised?
• What needs to be done to support workforce and preserve skills within the system?

The development of an Integrated Care Board constitution

The Bill charges CCGs within an ICS with developing the constitution for the Integrated Care Board (ICB) which will in time replace them.  Issues to consider include:-

• Which stakeholders should be closely involved in the development of the constitution and are there others that should be engaged with in other ways?
• What governance processes should support the development of the constitution?
• What procedures will the ICB adopt for decision-making, including arrangements for transparency?

ICB membership and mission

The Bill prescribes mandatory members of the ICB comprising a Chair, a Chief Executive and 3 “ordinary members” appointed by NHS Trusts and FTs, local GPs and Local Authorities respectively.  The recently published ICS Design Framework also requires a Director of Finance, Director of Nursing and Medical Director as well as at least 2 independent Non-Executives.  Directors of Public Health are also described as having an “official role” in ICBs.  It’s generally accepted that a board with more than about a dozen members is more likely to be unwieldy and relatively inefficient. 

• What skill mix will be required to make the ICB effective and will this extend beyond the above list of required members?
• How will groups of trusts, primary medical services providers and Local Authorities each select individuals as their “ordinary members” and what will be the expectations of that role?
• Is there enough common ground between stakeholders as to the vision and strategy for the system, as well as risks which may impact on that strategy, to create an outline Board Assurance Framework (BAF) for the ICB which can inform the developing governance arrangements?
• How will the ICB’s BAF interface with those of its partner organisations, and what changes might those organisations need to make to their own governance?

Arrangements at place

The concept of “place” is not expressly referred to in the Bill.  This serves as a reminder that the Bill provides systems with no more than high-level arrangements around which they themselves must build an effective system.  The role of place will of course be key.  The Design Framework describes a range of options for place-based arrangements, ranging from an individual ICB place director, to committees and the appointment of a lead provider to manage resources and delivery.

• Which option(s) for place based arrangements are best suited to your system?
• How can we preserve the value of existing local arrangements, such as s.75 partnerships and effective working with Health and Wellbeing Boards, within the new structures?
• How can we best promote alignment between the wide range of stakeholders, statutory and non-statutory, which must work together to deliver a population-based approach to health and care?

Integrated Care Partnership

The Integrated Care Partnership (ICP) will be constituted as a joint committee of the ICB and each local authority with public health functions within the ICB’s footprint.  The Bill proposes that its role will be to create an Integrated Care Strategy, defining how the ICB, local authorities and NHS England will together exercise their functions to meet the needs of those who live within the system.

• Who, in addition to the ICB and local authorities, will be invited to sit on ICPs?
• What common themes emerge from existing Joint Strategy Needs Assessments that could provide a basis for a first Integrated Care Strategy?
• How will ICPs and Health and Wellbeing Boards interface, and in particular will their membership differ or overlap?

We recognise that guidance on many of the above points will be produced by NHS England or DHSC over the coming months.  However, we expect that this guidance will define options and matters to consider rather than prescribing solutions.  It will still be for systems to develop and own their new ways of working.  With 9 months until April 2022, it can only be a good thing for systems to begin to address these issues now.

DAC Beachcroft’s healthcare team have worked with emerging ICSs and have been closely following the emerging thinking around the integration and innovation agenda in the sector.  Over the coming weeks, we will be publishing further briefings focusing on particular aspects of the Bill.  In the meantime, if you would like to discuss any aspects of the Bill and what it could mean for your organisation, please get in touch.