The Integrator: The 10-Year Plan’s unanswered questions

HSJ’s leaks from the 10-Year Health Plan last week confirmed the strength of this government’s passion for a return to a full-blooded purchaser/provider split, with integrated care boards expected to promote a thriving mixed market of providers.

Trusts will be removed from ICBs, integrated care partnerships will be abolished, and systems’ levers over capital spending will be eroded.

Many readers will regret the ongoing roll-back of integration policy. But there are some positives for this group, too. For example, there are signs of movement on significant primary prevention measures.

The proposed two contracts for neighbourhood health could also provide a pragmatic and flexible approach to meeting local needs. Along with the accoubtable care organisation-style “integrated health organisation” proposal, there may be a way to flex commissioning to suit a range of service and provider configurations. 

But there are many “ifs”, questions, and gaps to fill.

Must a multi-neighbourhood provider (ie NH lead provider) cover an entire “place”, or upper-tier authority? Can they coexist in an area with an IHO? Can they coexist with multiple single-neighbourhood providers? If so, how are resources split?

Will the huge amount of money and staff passing through primary care networks now be shifted into the control of the newly contracted providers? What else will be commissioned through the contracts? Does government really want them thrown open to the market? If so, will the Provider Selection Regime need to be tweaked to encourage more competition?

It looks like the intention is to create a leading role for GP federations and large-scale primary care providers. But how many of these can and will step up will depend on the detail of requirements, including financial, and the pace of change. In many areas, these organisations are immature and fragmented, lack robust governance, or appear too commercial.

The big fear of GP leaders is the government’s desire for rapid change will lead to a takeover by trusts and FTs. They see primary care’s voice being further sidelined in such structures.

ICPs are to be scrapped, while reconfigured ICBs will cover vast areas with fewer staff. The 10YHP is therefore expected to suggest neighbourhood services (which, remember, potentially cover a lot) will be planned by health and wellbeing boards, sitting at place level. That potentially gives a much bigger role to upper-tier councils. Will this prove a symbolic sop, or a real shift of budgets and decision making? We will see.

Which leaves the biggest question of all. Although many of the NH proposals are very familiar, what is being envisaged is a world away from what’s actually provided today in terms of access and standards of services, especially for the six high-needs groups. Huge service expansion and transformation is required, including in social care, which is largely left untouched by the 10YHP. 

Where is the extra funding for more staff and tech, to make these teams work, supposed to come from? Both the Royal College of GPs and British Medical Association GP committee are concerned at our revelation that the recent 10YHP draft had no real commitment to moving money in this parliament.

Using the stuff that’s there

It appears the government’s clear answer to the resources question will be, to quote government adviser Paul Corrigan, “we thought we’d use the stuff that’s there”.

This was reinforced by a disappointing Spending Review settlement, especially on capital, and illustrated by health and social care secretary Wes Streeting’s speech about health inequalities funding last week.

That he is speaking about health inequalities – after a period of deafening quiet on this and public health – is great news (even if it is motivated by party politics). So is the promised review of the broken GP funding formula (although it won’t deliver any time soon). The prospect of targeting prevention work at those who need it most (currently it flows the other way), as I suggested in February, is also welcome.

But where the speech was wildly misleading was when it implied £2.2bn of “deficit support” would be re-targeted “this year” at the poorest areas, to help reduce inequalities.

First, if there is a mysterious method available to recover the £2.2bn from spending plans this year, it is not one which any of those areas currently burning through it are yet aware of. Even doing so next year will be a mammoth ask.

Second, big chunks are already spent in some pretty deprived areas: Lancashire (where the speech was made), Merseyside, Greater Manchester, Essex, and south east London. Many of them will be net losers when – as NHS England CEO Sir Jim Mackey has already said he would like to do – funding is redistributed via the existing “fair shares” ICB allocation formula.

Sir Jim’s plan is certainly a case of “using the stuff that’s there”, and it might be a good way to restore financial discipline in a health system. It might even be fair. But it is not free money, nor a solution to health inequality.

Mr Streeting’s speech also further irritated many in local government, by making no mention of them despite their leading role in public health. Councils already felt sidelined by the surprise announcement of ICB cuts and restructuring, which they fear will disrupt local partnerships and result in cost being shunted to them for work like safeguarding. Whether they are cheering for the 10YHP this week, or sitting firmly on the fence, will be instructive.

Reverse takeover

The new Department of Health and Social Care structure revealed last week also highlights some concerns for the public health agenda. There is no mention among directorate responsibilities of health inequalities or the government’s “health mission”. It’s probably just an oversight – albeit a telling one. But the Office for Health Improvement and Disparities is definitely a dead duck, and there’s no strengthened external agency to replace it.

Moreover – although it is NHSE that is being abolished – there is every risk of a “reverse takeover”. Departmental business may become ever more dominated by NHS concerns, as it was in the noughties.

Perhaps the most striking thing about the new structure is how many responsibilities are shared by both the permanent secretary, former trust CEO Sam Jones, and Sir Jim, a trust CEO taking a break from his Newcastle FT day job.