HCL Issue 10 - Page 16

16 INSIGHT concerns that the body lacked ‘democratic oversight’. The council will reassess the move this spring. NHS England suggested in the long-term plan that ‘legislative change would support more rapid progress’, helping organisations work in a more integrated way. This is because individual organisations have been used to working autonomously, which could add a new layer of challenges in the transition towards integrated care. BMA feared that ACOs lacked clarity In the UK, the term was initially used in two contexts: accountable care systems (ACSs) and accountable care organisations (ACOs). The legitimacy of the latter was criticised and examined through two judicial reviews last year. Campaigners and trade unions including the BMA feared that ACOs lacked clarity and, indeed, accountability, and could favour the privatisation of the NHS as private companies could bid for an ACO contract. ACSs were later rebranded as ICSs as part of NHS England’s Refreshing NHS Plans for 2018/19. However, despite the name change, it is still unclear who will be held accountable in an ICS. NHS England hopes to tackle this through the introduction of a new ICS accountability and performance framework to ‘consolidate the current amalgam of local accountability arrangements and provide a consistent and comparable set of performance measures’. However, this framework hasn’t been released yet. ‘There is a question of where that accountability is going to sit,’ says Ms Curry. Healthcare Leader 2019 Issue 10 ICSs are systems made up of organisations. They are the servant of the organisations, not their master ‘At the moment, we have a split between commissioning and providing, and the commissioners clearly have a role to hold those providers to account. ‘In an ICS, I am not sure it’s clear that we’ve got somebody saying I’m going to hold you to account for this. It’s not to say it can’t happen, but it hasn’t yet been articulated clearly. ‘The biggest risk is the loss of accountability. In local government, there is a very clear democratic accountability. They are held to account by the electorate. Within health, we don’t have that. At the moment, commissioners fulfil that function, and maybe they still will, but it is not completely clear.’ In the case of Nottingham and Nottinghamshire ICS, this lack of clarity resulted in Nottingham City Council’s decision to suspend its collaboration with the ICS in December 2018, following ‘Obsession with structure can be unhelpful’ In order to support the effective running of ICSs, NHS England suggested in the long- term plan that Parliament should allow trusts and CCGs to make joint decisions by giving NHS foundation trusts ‘the power to create joint committees with others’. This would allow them to create ‘joint commissioner/provider committees in every ICS, which could operate as a transparent and publicly accountable partnership board’. ‘I think the legislative change and clarity on the accountability framework would help,’ says Ms Curry. ‘There are talks about ICSs working as a system and organisations working together towards common goals, but the ICSs themselves are not going to be statutory bodies.’ Allowing ICSs to become statutory bodies could be counterproductive, according to Mr Webster. ‘ICSs are systems made up of organisations. They are the servant of the organisations, not their master. ‘They are supported by governance arrangements that allow joint decision- making where required. ‘The more we consider ICSs as organisations, the more likely we are to damage relationships and the pace of improvement. Our obsession with structure in the NHS can be unhelpful.’ There is agreement among clinicians and policymakers that integration is the way forward. It is not likely, however, that the health and social care sector will see any change to legislation to favour integration any time soon, as other more pressing issues – such as Brexit – are likely to push it into the background. STPs will have to continue to work with the information that is available to them while they wait for NHS bosses to release further details – including the new ICS accountability and performance framework – on how local systems should achieve ICS status by April 2021. It seems the exact nature of the transition is very much a work in progress. More online For more on integrated care and other health sector analysis, visit healthcareleadernews.com