Response to the NHS England and NHS Improvement consultation on next steps for ICSs

Our response to the consultation, January 2021

People talking to each other

The consultation

This is our response to the NHS England and NHS Improvement consultation “Integrating care – next steps to building strong and effective integrated care systems across England” on the future role and structure of Integrated Care Systems (ICSs), which ran from November 2020 to early January 2021.

Our response

Q4. Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?

AOP response: Agree

In our response to the 2019 consultation “Implementing the NHS Long Term Plan” we broadly supported NHS England’s and NHS Improvement’s proposals for legislative and other changes, subject to some important qualifications which still stand.

For instance, we supported the proposal that NHS organisations should work with each other, primary care networks and other partners as ICSs, as long as decision-making structures give a voice to all the primary care NHS professions including Local Optical Committees (LOCs), and potential conflicts of interest are robustly managed. We also noted that core primary care contracts, such as the General Ophthalmic Services (GOS) contract, should be retained at national level to ensure an adequate foundation level healthcare offer across the population.

In principle we welcome the shift in local NHS commissioning in England from Clinical Commissioning Groups (CCGs) to ICSs. We have long argued that extended primary eye care and community monitoring services should be commissioned in England either at national level, or failing that, on as wide a scale as possible using nationally endorsed pathways. This will support ongoing work under the National Outpatient Transformation Programme to move more eye healthcare into the community in pursuit of the Long Term Plan. The delays in commissioning the new Coronavirus Urgent Eyecare Service (CUES) in some parts of England during the COVID-19 pandemic, because of fragmented commissioning at CCG level, have further demonstrated the need for extended eye care services to be commissioned across a wider footprint.

The current consultation paper sets out the case for ICS governance to be put on a more formal basis. We agree that given the growing role and responsibilities of ICSs, they should be put on a statutory footing.

This consultation question also refers to the other legislative proposals needed to provide the right foundation for the NHS. Some of the proposals in the 2019 consultation involved significant changes which could have negative effects for patients unless the resulting risks are managed. For instance, the 2019 consultation proposed a new ‘best value test’ to manage the risk that removing the current procurement rules could lead to less rational and transparent commissioning. The current consultation has not provided any further detail on this, and it is vital that primary care providers have an opportunity to provide input to detailed new proposals before legislation is brought forward.

Q5. Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems to Parliament and most importantly to patients?

AOP response: Agree

The consultation paper states that both options for giving ICSs a formal legal basis – a statutory Board/joint committee with an accountable officer, and a statutory ICS body – will involve broad membership and joint decision-making, including as a minimum representatives from commissioners; acute, community and primary care providers; and local authorities. The consultation paper says (in para 3.21) that “there would be a representative for primary care on the Board” of the statutory body model. As we have said in our response to Q4, we think any statutory ICS model should be designed to ensure genuine representation and involvement of all parts of primary care.

This could involve formal representation of each of the four pillars of primary care – optical, general practice, pharmacy and dental – with LOCs representing optical practices. Alternatively, an ICS could include a formal collaboration of primary care providers, working together to ensure that a primary care representative on the ICS truly gives a voice to all four primary care pillars. This model has already worked successfully in some areas.

Subject to this vital point, we agree that consultation option 2, the statutory ICS body, is the better option because it will remove residual CCG accountability structures, and will address concerns about clarity of leadership more effectively than option 1.

We also note that the need for full engagement with primary care also applies to place-based collaboration. Primary care should be involved in place-based initiatives from the start, to avoid missed opportunities and the difficulties that have affected Clinical Commissioning Groups.

Q6. Do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?

AOP response: Disagree

It is reasonable that ICSs should have the flexibility to shape their governance to meet local needs. However, we have answered ‘disagree’ to the consultation question because we think it is vital that ICS membership should always give a voice to the full range of primary care contractors, as discussed in our answers to Q4 and Q5. This is because the care that primary care contractors provide will be a core part of NHS service provision in every ICS area. There should be minimum national standards to ensure this representation for primary care, with additional local flexibility to allow systems to fine-tune their governance arrangements.

Q7. Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies?

AOP response: Strongly disagree

As discussed in our answer to Q4 and our response to the 2019 consultation, we think the General Ophthalmic Services (GOS) contract should continue to be commissioned by NHS England at national level, to ensure an adequate foundation level healthcare offer across the population.

Optometry practices provide more than 13 million NHS sight tests across England every year under the GOS contract, including vital domiciliary services for patients who cannot visit a practice. The GOS sight test is a core part of NHS service provision in every part of England; it identifies vision problems so they can be corrected, and detects serious diseases such as glaucoma and macular degeneration before the patient even notices symptoms.

Moving GOS commissioning to ICS level would offer no benefit whatsoever in terms of meeting local population need. However, it would generate additional costs and complexity both for commissioners and providers, particularly given the need for safeguards to ensure that GOS is commissioned to the same standard and the same level of service availability in each ICS area to avoid health inequalities.

The current national contracting arrangements for GOS, coupled with competition between GOS providers, ensure a high level of patient choice and service availability (NHS sight tests are widely available on demand), and provide excellent value for money for NHS England and the taxpayer. They also provide a firm foundation for wider commissioning of extended services in ICSs, as discussed in our answer to Q4. Maintaining GOS commissioning on a national basis will enable optical primary care providers to continue to work at scale, while also meeting the additional needs of patients in each ICS footprint through extended services.