I wrote last week about the new White Paper published by the government, and what it means for general practice.  My sense at the end of the White Paper is that I am less clear now than I was before as to what exactly is meant by “integration”.  Does it mean removing the barriers between organisations to enable joined up care, or does it in fact mean a further centralisation of control?

I understand the logic of integration, and why it is perceived to be a ‘good thing’.  Years of an internal market have created divisions and rivalries within the health service, and led to behaviours focussed on the needs of individual organisations rather than necessarily what is best for the patient.  It makes sense, then, to take steps to remove these artificial barriers created by the system, and for the organisation of care to be centred on what is best for patients.

There is, however, a difference between removing the barriers that have prevented health and social care professionals from working across organisational boundaries and centralising control into single organisations.

The new statutory NHS Integrated Care System (ICS) bodies will be given more formal power, “In order for ICSs to progress further, legislative change is now required to give ICSs stronger and more streamlined decision-making authority” (White Paper 5.4).  Further “each ICS NHS body… will be directly accountable for NHS spend and performance within the system” (6.18 f).  The NHS is well known for its mindset that accountability cannot be exercised without control.  Indeed, the system’s experience of the regional tiers of NHS England points very much to the fact that centralised control is something NHS England is extremely comfortable with.

All organisations within the NHS will not be merged into these new ICS bodies.  How, then, could control be exercised by the new system?  Well there are “several further changes to reinforce or enable integration” (the actual words used, 5.13 of the White Paper), one of which is a new “duty to collaborate” (3.11) imposed on all organisations across the system.  It does not take a huge stretch of imagination to envision a situation where any organisation not complying with the central diktats of the new ICS are taken to task for failing to comply with the new duty to collaborate.

The White Paper does talk about “the primacy of place” (6.5), and by place it means local areas within an ICS, but it only goes on to say that place is important, and not how this primacy should be effected.  Instead the government is not, “making any legislative provision about arrangements at place level – though we will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14).

Worrying, then, that a centralist-minded ICS would be able to set up its own arrangements for how arrangements in local “place” areas will work, with as many control mechanisms as it likes.  The argument is that by not legislating the arrangements that work best in any local area can be made, but that does leave it wide open to local interpretation/abuse.

We are therefore left with a situation, embedded by a new legislative framework, that seems designed to bring about integration not through relationships but through a system of centralised control.  How it works in practice will be dictated by the way NHS England behaves with the new ICS’s, and how the local leaders then operate within their own area.

Now I am generally a glass half-full individual, and of course there will be local leaders who focus on empowering and enabling local teams.  But I suspect this will be the exception rather than the rule, and so all of this leaves me feeling less than optimistic about the future.