Written evidence submitted by The BMA (ICS0046)

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

Summary

• The BMA supports the principle of integration and has campaigned strongly for a collaborative NHS.
• The Health and Act 2022 places Integrated Care Systems (ICSs) on a statutory footing, which should help ensure they are held to account for delivering against their objectives.
• However, we are concerned that the permissiveness of the Health and Care Act and remaining questions over the level of guidance to systems, and mechanisms for holding systems to account, could result in unwarranted variation across systems and present difficulties for some ICSs in meeting centralised targets.
• In particular, the potential level of variation with regards to clinical leadership and representation within ICSs risks postcode lotteries developing between areas. BMA analysis of ICBs (Integrated Care Boards) has a revealed a critical lack of clinical leadership and voice within the newly statutory bodies, limiting their understanding of the challenges facing frontline services and staff.[1]
• If ICSs are to be successful it is essential that they embed the active involvement of clinicians and frontline staff, who know their local healthcare systems and patients best, at all levels. Clear recognition of the importance of the role of clinical leadership, representation, and engagement within the CQC’s (Care Quality Commission’s) assessment and NHSE’s oversight of ICS performance and development is needed.
• This must include formalised roles for LMCs (Local Medical Committees) and LNCs (Local Negotiating Committees) on ICS boards, as well as strengthened representation from primary care, secondary care clinicians and independent public health doctors within ICBs in particular.
• It is essential that patient involvement is also embedded throughout ICSs, and that their experiences of care shapes the plans and activities of systems. This should also be incorporated into CQC and NHSE assessment of ICS performance and development.
• It is also essential that ICBs and ICPs (Integrated Care Partnerships), as the central functions of an ICS, include an independent, properly qualified, and appropriately registered Public Health Consultant in their decision-making structures and boards. A professional, independent public health voice is vital to ensuring there is a focus on health improvement across the whole ICS population, but again, this has been lacking in many ICSs to date.
• Providing for adequate clinical leadership and patient involvement within ICSs should help ensure ICSs are better able to both meet the needs of their local populations and support them in meeting centralised targets in respect to prevention, safe staffing and the elective recovery.
• It is also important that local systems are supported in meeting centralised targets by ensuing there is a focus from Government on providing the funding, workforce and infrastructure needed for ICSs to be successful.
• The development of ICSs, and STPs before them, has been marked by examples of opacity and lack of direct, meaningful engagement with doctors, staff, and the public. To ensure accountability, it is therefore vital that transparency, and patient and clinician engagement are priorities for all ICSs as they continue to develop and bed in.  
• ICSs should also be expected to demonstrate their commitment to medical research and health education and to learn from both.

1. How best can a balance be struck between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for doing so?

1.1 Whilst the BMA recognises the need for flexibility within ICSs to address the particular needs of local populations, we are concerned there is currently an imbalance between enabling that flexibility and limiting unwarranted variation.

1.2 The provisions currently set out in the Health and Care Act[2] and further detail in the NHSE ICS Design Framework,[3] fall far short of ensuring strong clinical leadership and representation and risk postcode lotteries developing. Doctors who have in-depth knowledge of their local healthcare systems are best placed to make decisions about what is needed in the best interest of patient care. Local systems without strong clinical leadership may therefore be less successful in meeting their duties to commission services and develop plans that meet the needs of their local population. 

1.3 Whilst placing ICSs on a statutory footing should improve their accountability and transparency, it is vital they do not lose some of the positive elements of CCGs. This includes their vital function in ensuring accountability to clinicians and patients as a body of elected, local GPs, their invaluable local knowledge, their role in providing a strong clinical voice and their skill and experience in commissioning services.

1.4 As an NIHR (National Institute for Health and Care Research) study[4] that ran from 2013-2016 found, despite challenges and limitations, CCGs offered a platform which promoted some notable primary care-led innovation, gave greater prominence to primary care and, in turn, promoted the wider perspective of well-being as well as health. They have also ensured local knowledge and patient voices have been better reflected, whilst peer pressure has in many areas raised the quality of general practice. Clinical leadership was found to have a distinctive role in any new approaches to service delivery and in enabling front-line clinicians to work out the practical detail of any new service. 

1.5 LMCs (Local Medical Committees) and LNCs (Local Negotiating Committees) – which represent GPs and secondary care doctors respectively – have frequently reported low levels of engagement with their local ICSs. It is critical, therefore, that ICSs reach out to and actively involve their local LMCs and LNCs – including ensuring they have formal roles within their boards and decision-making structures.

1.6 It is also essential that ICBs and ICPs, as the central functions of an ICS, include an independent, properly qualified, and appropriately registered Public Health Consultant in their decision-making structures and boards. A professional, independent public health voice is vital to ensuring there is a focus on health improvement across the whole ICS population, but again, this has been lacking in many ICSs to date. The focus that some ICSs have on ‘population health management’ is insufficient as this only covers part of what a good public health specialist does. Public health representation and engagement must also extend beyond engagement from a local authority Director of Public Health, which would risk them representing their employer rather than the ICS population as a whole.

1.7 Clear NHSE guidance to systems, best practice sharing and ensuring ICSs are held to account for their performance is therefore essential to ensuring they achieve their statutory duties whilst working flexibly.

1.8 As highlighted in the BMA’s response to the NHSE ICS System Oversight Framework,[5] this should include defined metrics that are subject to scrutiny and published publicly, as well as a more explicit focus on clinical leadership, representation, and engagement. Clear recognition of the importance of the role of clinical leadership, representation, and engagement within the assessment of ICS performance and development is needed. This must include formalised roles for LMCs and LNCs on ICS boards, as well as strengthened representation from primary care, secondary care clinicians and independent public health doctors within ICBs in particular.

1.9 Equally, it is essential that patient involvement is also embedded throughout ICSs, and that their experiences of care shape the plans and activities of systems. This should also be incorporated into the assessment of ICS performance and development.

2. Are central targets consistent with local autonomy in this context?

2.1 There is a risk of friction between the responsibility of ICSs to meet centralised targets and ICSs’ autonomy over their operation and ongoing implementation. Monitoring how ICSs are performing against these centralised targets will be key to determining how they are managing balancing centralised targets with local autonomy. Further information on how NHSE will monitor performance against targets for ICSs would be helpful to better understand the relationship between central targets and ICS performance.

2.2 A major outstanding question remains over whether or how ICSs will be collectively judged on the performance of individual member organisations – i.e. NHS trusts. Will ICSs as a whole be deemed to be failing if some NHS providers within their boundaries are not meeting central targets, or will an aggregate target be applied to the entire ICS? Likewise, where individual providers are failing to hit targets, will NHSE intervene with them directly, or allow the ICS autonomy to resolve the situation independently?

2.3 NHSE has already set ICSs the challenge of finding efficiency savings to address funding shortfalls and breakeven for the year. Different systems will face different issues in meeting these savings, with some likely to struggle more given differing local challenges and deficit sizes. To enable ICSs to exercise their local autonomy in a way that delivers improvements, it is therefore vital that ICSs be given proper funding and time to develop, with patient care and the integration of services prioritised ahead of financial imperatives and savings.

2.4 Assessment of ICSs’ financial performance and subsequent decisions should also consider the wider fiscal environment in which they operate, including current and historic shortfalls in NHS funding for systems, Trusts, and services. Even the best possible support package will be ineffective if there is insufficient funding.

2.5 ICSs have an important role to play in ensuring a focus on research, innovation and learning throughout local systems and NHS organisations operating within them. Whilst research and innovation must be supported at a national level through central government investment, ICSs should be given the flexibility to support research activities that are of most relevance to their local population.

3. To what extent is there a risk that ICBs become an additional layer of bureaucracy if central targets are not reduced as ICBs are set up?

3.1 As previously highlighted, given the significant differences in their geographies and demographics, some ICSs will face more significant local challenges than others, resulting in greater difficulty meeting centralised targets or an increased likelihood of disconnect between targets and local priorities.

3.2 NHSE and ICBs should look at agreeing local targets where possible that compliment national targets but reflect the unique set of challenges facing each system.

3.3 Central to this will be the delegation to place-based partnerships and provider collaboratives, which the ICS Design Framework has established will each be key components in enabling ICSs to deliver their core purpose, improve patient care and ensure efficient use of resources.[6] However, there has been limited detail set out on how the interface between ICSs, place-based partnerships and provider collaborates will work in practice. Further information on how these systems will function alongside each other is necessary to understand how ICSs can most effectively operate within the context of centralised targets.

4. What can be learned from examples of existing good practice in established ICSs?

4.1 The BMA has heard from our LMC and LNC members, as well as BMA staff in member relations, that there is currently considerable variation between ICSs that are operating effectively and ICSs that are currently less well developed. For example, whilst some systems are ensuring there is regular engagement with local clinicians, LMCs and LNCs, there are others where there has been little if any ICS or ICB engagement.

4.2 There is considerable variation between ICSs in terms of the involvement of LMCs, LNCs and public health doctors, with many LMCs and LNCs reporting feeling unengaged. BMA analysis of all 42 ICB constitutions has confirmed a dearth of both clinical leadership and public health expertise within ICBs.[7]

4.3 This lack of clinical leadership and voice is most apparent in secondary care, with none of the 42 ICBs making any provision within their constitutions for a dedicated clinical voice for hospital doctors. While Medical Director positions do exist in every ICB, these are open to any qualified doctor and those appointed to them may not be working in secondary care. This situation risks leaving all secondary care representation on ICBs to managers, failing to give a voice to doctors with ongoing experience and knowledge of frontline secondary care services, and, consequently, leaving a critical gap in the capacity of ICBs to properly understand and address the challenges facing hospitals and their staff. It is critical that frontline, secondary care clinicians have a strong voice within ICBs, including a formal role for LNCs (Local Negotiating Committees) on their boards, alongside the current medical director position.

4.4 Our analysis has also found that 26 ICBs have only the statutory minimum of one primary care representative on their boards, and only 17 of the 42 ICBs directly specify that their primary care representative will be a GP. It is equally concerning that only one ICB constitution lists a local LMC (Local Medical Committee) as an observer (non-voting) member of its board, indicating a worrying absence of a voice for local GPs within the developing structures. More comprehensive and consistent GP leadership is essential within ICBs alongside formal roles for LMCs across every ICB.

4.5 The BMA’s review has laid bare a critical lack of public health expertise within practically every ICB’s leadership, too. Only two ICBs set out a specific, qualified, and voting public health member on their boards – West Yorkshire ICB, which sets aside a position for a Local Authority DPH (Director of Public Health), and Somerset ICB, which includes a position for a dedicated public health expert. Seven other ICBs have established that at least one of their voting members must bring knowledge and experience of public health, with an expectation that this would typically come from Local Authority members. While 13 ICBs set out non-voting participant or observer roles for DPHs and public health specialists.

4.6 Disconcertingly, though, a total of 20 ICB constitutions fail to note any public health expertise within their boards at all. This is of particular concern, given the importance of expert public health advice in informing population health approaches and ensuring a focus on tackling inequalities. It is essential that all ICBs have independent, properly qualified public health experts on their boards, in order to ensure that their decision-making and their commissioning reflects the importance of public health and prevention to the NHS. 

4.7 These shortages of, and variation in, clinical leadership must be identified and addressed to ensure ICSs have the necessary skills and expertise to carry out their functions in improving the overall health of their local populations and tackling inequalities.

4.8 Likewise, it is imperative that as ICB ‘place’ level structures develop, they also have comprehensive clinical leadership, from primary care – including LMC representation, secondary care – including LNC representation, and an independent, properly qualified public health expert. This is especially essential if, as has been intimated by NHS England and others, ICBs devolve significant power and resources to these place-based structures.

4.9 The complexity of governance systems for delivering change and structures for scrutinising within ICSs have also been highlighted as a challenge. Different levels of scrutiny at footprint and regional level, coupled with varying levels of staff level involvement, have created obfuscation and bureaucracy making it difficult to hold systems to account for their performance.

4.10 In the South West, Devon has been highlighted as a system that is well developed despite facing challenges. They have pursued regular meetings with BMA LNC representatives and, since early on, their SPF (Social Partnership Forum) has become a model to copy. They have also pursued innovative approaches within the system, such as the purchase of the former Nightingale unit in Exeter to provide additional capacity for diagnostics and possible elective work across the peninsular.

4.11 It is vital ICSs have mechanisms for learning from examples of best practice and that there are mechanisms for embedding good practice across all 42 systems, for sharing research findings and innovation and of ensuring that they are relevant to local patients and populations. This should include sharing best practice models for ensuring clinical leadership and engagement, as well as transparency and accountability. Regional SPFs and the national SPF have an important role to play here.

5. How can it be ensured that quality and safety of care are at the heart of ICB priorities?

5.1 Clinical leadership and patient representation within ICSs are key components to ensuring that quality and safety of care are at the heart of ICB priorities.

5.2 Local clinicians play a vital role in the health of their local areas and enabling locally led change, as highlighted in the case of primary care by the Fuller Stocktake report,[8] and it is this locally led change that was a vital component in successful COVID-19 pandemic responses, such as the vaccination programme.

5.3 To help ensure the quality and safety of care are prioritised, clinicians must be given a leading voice and role at every stage of the ICS, including on the ICB Itself, and these roles must be adequately funded, and staff given the time needed to fulfil them. This should be further reinforced by ensuring there is the funding and infrastructure in place to support ICBs deliver the changes needed to improve the quality and safety of patient care.

5.4 The NHS is currently facing a huge backlog in care, with the latest figures for May 2022 showing a record of over 6.6 million people waiting for treatment in England, whilst covid cases and hospitalisations remain concerningly high. As a result, waiting times are increasing with the total number of patients waiting over 18 weeks for treatment now standing at 2.41 million.[9]

5.5 Getting the backlog under control is key to improving care quality and enabling ICBs to focus on this as a priority. The BMA estimates that an additional £7bn funding over what the Government has already pledged is needed to tackle the non-COVID care backlog, including funding set aside for primary care to support those waiting for treatment.[10] Accounting for inflation since this analysis was carried out, this figure will now be higher.

5.6 Action is also needed to help address the severe workforce shortages facing the NHS. Safe staffing is a prerequisite to ensuring the safety of patient care, but the NHS is in the midst of a chronic workforce crisis, driven by years of insufficient investment in training new staff, inadequate workforce planning, and lack of government accountability.

5.7 This was unequivocally recognised and evidenced in the Health and Social Care Committee’s recent report on recruitment, training and retention, which concluded the NHS was facing “the greatest workforce crisis in history, compounded by the absence of a credible government strategy to tackle the situation”.[11]

5.8 BMA research shows England would need the equivalent of an additional 46,300 full time doctors just to put us on an equivalent standard with the EU OECD average, whilst levels of fatigue and burnout among staff are at record highs.[12]

5.9 As found by the Keogh report of 2013,[13] a focus on research and education by health organisations and staff helps ensure that NHS Trusts and Foundation Trusts provide high quality care.  Amendments to the Health and Care Act place a duty on ICBs to facilitate research and require that the discharge of this duty is considered in the NHSE’s annual performance assessment of each ICB. However, this falls short of fully addressing the importance of a focus on research and education. ICSs should be expected to demonstrate a commitment to promoting and learning from research and education as part of their wider commitment to high quality patient care and population health.

6. How can a focus on prevention within ICSs be ensured and maintained alongside wider pressures, such as workforce challenges and the electives backlog?

6.1 As with equitable outcomes, strong public health and primary care representation throughout ICSs is key to ensuring prevention as a primary focus. To this end, it is vital that ICBs and ICPs, as the central ICS functions, include registered specialists in public health and experts from across primary care. This is key to developing genuinely integrated services which focus on prevention and early intervention, shape services around the needs and wishes of individual patients and the wider population and maximise the efficiency and effectiveness of whole systems. This must further be reflected in the membership of ICS sub-committees, which we understand will play a central role in taking forward priority workstreams. 

6.2 Representation and engagement from across primary care is key to prevention and ensuring that the voice of frontline clinicians is represented in the interests of patient care, as emphasised by the BMA’s work with primary care colleagues including the British Dental Association, Pharmaceutical Services Negotiating Committee, Optometric Fees Negotiating Committee and National Community Hearing Association, during the passage of the Health and Care Act.[14] To this end, we support calls for mandated roles for primary care professionals within ICPs and for ICBs to consult primary care Local Representative Committees when preparing and revising their five-year plans.

6.3 It is worrying that a number of ICSs have failed to include additional roles for clinicians, including independent public health experts on their ICBs. The lack of independent public health expertise and advice available to boards poses a significant risk to the role and prominence of public health and the focus on both prevention and equitable outcomes that ICSs are quite rightly meant to have. Given the expectation that ICSs will act as population health organisations, this is a shocking omission that needs to be addressed.

6.4 Meaningful leadership and engagement from frontline clinicians who know the challenges and pressures facing their local areas best, will also help ICSs focus on addressing workforce challenges and tackling the electives backlog. A formalised role for LNCs and LMCs within ICS boards, would help ensure systems are aware of the impact of the electives backlog and workforce pressures on the local healthcare system and patient care, and are able to develop the best approaches for addressing them.