What can ICBs decide to do? (Decide? Do?)

Yesterday I shared my thoughts about why, throughout much of last year, the Government were immobile in making anything happen with the NHS. This was partly caused by putting NHSE staff in such a position that everyone had to spend most of the year applying for their own jobs whilst simultaneously cutting large numbers of staff. And partly because the Government spent most of the last year regularly changing both the incentives and goals they expected local NHS leaders to achieve.

It would have been very helpful for local NHS leaders to have had a whole year to plan within parameters set by the centre rather than having them changed every few months. But that has not been the case.

Today I want to look at how the other organisations charged with performance management – the NHS, and the Department of Health and Social Care are encouraging ICBs to develop and implement their work.

(Incidentally, mustn’t it be great having two national organisations having a remit to tell you what to do?)

I am sure that several of my readers may well be, in your day jobs, trying to get ICBs to move with speed in developing aspects of a new model of NHS care. Perhaps to increase prevention or to do more about health inequalities. Certainly, these are the activities that many people who, when they were set up, looked with hope to ICBs to tackle.

But most of those I approach seem quite timid about bending their work in the direction of new goals. This seems rather odd because most of the outputs we are trying to get ICBs to produce can be found in most of the integration strategies that they published earlier this year.

These are genuinely visionary documents. Taken together, if only half of each plan were to be executed there would be a big improvement in the health and health care of the public. But when you suggest to ICBs that they might actually implement their own plans, senior staff look at you as if you are extremely naïve. These are plans, don’t confuse them with actions.

I was wondering why some pretty good people aren’t implementing their own plans.

But no more.

Last week I came across the DHSC Guidance to ICBs published on 19/10/2023, Shared outcomes toolkit for integrated care systems.

Have a look at this paragraph to get a flavour of how the DHSC is guiding 42 ICBs.

“Plans and strategies at system and place levels should reflect outcomes and priorities set out in national frameworks such as the NHS Mandate, the NHS Oversight Framework, the Adult Social Care Outcomes Framework, the Better Care Fund Framework, the Public Health Outcomes Framework and the Care Quality Commission Single Assessment Framework. System-level plans and strategies, including the Joint Forward Plan developed by the ICB and the integrated care strategy developed by the ICP, should complement place-level plans such as place-level shared outcomes and the joint local health and wellbeing strategy developed by the health and wellbeing board.”

This is so bad on so many levels.

Firstly, if the job of ICBs is to integrate the NHS with other services, why is it that the Department, at a national level (that incidentally organised the legislation that set them up), demands that they report upwards to so many people who wrote fragmented frameworks. It’s difficult to integrate when you are being performance managed in such a fragmented way.

Each of these frameworks within DHSC or NHSE (or both) will have a group of staff performance managing the way in which 42 ICBS are carrying out their specific framework. They will be demanding that every ICB regularly reports to them about how they are implementing their specific framework. Let’s pretend that an ICB is succeeding in integrating care. It will literally have to deconstruct that work to report in so many different ways.

This encourages ICBs to performance manage downwards – towards their places – in a similar fragmented way. And in the end no-one has the space to integrate anything.

Secondly, does no-one actually read this stuff before they send it out? You can imagine someone drafting this paragraph making sure that they have included every framework in the list – ticking them off to make sure they have them all. Well done! Good first draft.

But then you would hope someone else would, towards the end of the publication process, read it from the point of view of a CEO of an ICB for whom it is written. You would hope that that someone would read it with the thought, “What sense will a CEO make of what we are saying?”. And if you reviewed it with any empathy for the ICB senior manager who is the intended audience, you would conclude that “we really can’t say that”.

And the final issue this guidance raises leads me to the difficult conclusion that Boris Johnson was wrong about something.

Before ICBs CEOs were appointed the NHS had a significant injection of money from the Treasury. The then Prime Minister assured the country that this would not be spent on middle managers. A few weeks later the adverts went out for the new ICB CEOs with a pay ceiling of £270,000.

This did seem like a lot of money. But to help Boris keep his promise he could legitimately say ICB CEOS are NOT middle managers. They got the big bucks because they were doing very senior leadership jobs. So, Boris could get away with spending more money on NHS management because these were very senior managers.

However, we now see that the DHSC wants to prove the previous prime minister wrong. We may be paying people up to £270,000 a year, but actually we are treating them as middle managers.

This form of performance management makes them middle managers by ensuring that all the senior decisions are taken above their level.

We tell them what to do and how to do it.