Latest moves on legislative change for the NHS in England

In November 2020 NHS England published Integrating Care: Next steps to building strong and effective integrated care systems across England.

This follows extensive engagement in 2019 on options for legislating to remove some of the worst aspects of the market system in the English NHS brought about by Andrew Lansley’s disastrous Health & Social Care Act 2012. UNISON played a prominent role in last year’s discussions and achieved many of the outcomes we wanted to see in the proposals, including an end to the default assumption of competitive tendering within the NHS; the removal of Monitor / NHS Improvement’s competition enforcement role; and providing a vehicle for integrated care provider contracts to be held by public providers.

These proposals are all reiterated in the latest document and there are now further plans to put Integrated Care Systems (ICSs) onto a firmer statutory footing – these are the systems that have been developing over the past two years within local health economies in England as more advanced versions of Sustainability and Transformation Partnerships (STPs) that should bring together the key local NHS bodies along with a role for local government.

Integrated Care Systems
The document lays out two options which it thinks could be used to enshrine ICSs in legislation “without triggering a distracting top-down re-organisation”. The first is a relatively minimal change involving setting up a mandatory statutory ICS Board (with an Accountable Officer) through a joint committee that would enable local NHS commissioners, providers and councils to take decisions collectively. The second option goes further by establishing a statutory corporate body at the ICS which would bring the functions of clinical commissioning groups (CCGs) into the ICS. The ICS would then gain the ability “to delegate responsibility for arranging some services to providers”. The document has a firm steer in favour of the second option and this is the only one on which the document actively seeks views.

The document acknowledges the disruption such change will cause for those currently working at CCGs but does offer a “continued employment promise” for staff carrying out commissioning functions, along with a commitment to “preserve terms and conditions to the new organisations (even if not required by law) to help provide stability and to remove uncertainty.” NHS England says it will prioritise “the continuation of the good work being carried out by the current group of staff” and will “promote best practice in engaging, consulting and supporting the workforce during a carefully planned transition, minimising disruption to staff.” It is pointed out however that the most senior leaders in CCGs, such as chief officers, will be more directly affected by the proposed changes.

Other proposals
Other proposals in the document include a requirement for all NHS providers to become part of a provider collaborative which would, among other things, be used to support workforce planning across health economies. Systems will “move away” from activity-based commissioning, such as the Payment By Results system that has been a core part of the NHS market since it was introduced in 2004.

By April 2022, each ICS is expected to create “one workforce strategy” in line with the NHS People Plan. This would be designed to enable healthcare staff to work across the entire system – by using “practical tools to support agile and flexible working” and by mechanisms such as passporting or accreditation systems that enable staff to work in different places without their terms and conditions being affected.

Although the exact details are not yet known, the plan is to bring a Bill to Parliament in 2021 and for legislative changes to come into force in 2022.

UNISON response
NHS England is seeking responses to its latest plans (up until 8 January) and the potential implications of the changes are already the subject of discussion in existing partnership forums in England. UNISON’s written submission will reiterate our support for plans which move away from the market enshrined in the Health & Social Care Act and previous health legislation.

In order to provide a UNISON steer on the latest plans for ICSs, the union will use a number of key principles to guide our response. These will use Motion 62 (“Reorganisation without end: NHS commissioning and arms length bodies”) and Emergency Motion 1 (“Calling time on the Lansley Act”) passed at the most recent Health Conference in April 2019 as a basis.

The principles are laid out below:

  • Opposition to the use of market mechanisms and support for more collaborative working across the NHS
  • An ambition to remove the split between purchasers and providers on which the NHS market has been based since 1991
  • Proper funding and realistic timescales for any changes that are ultimately brought about
  • Protection for health workers’ jobs and terms and conditions, as well as the ability for them to continue performing their duties to the best of their abilities during any transition to a new system
  • Ensuring a more “future-proofed” system to minimise the need for further overhauls of NHS structures
  • Clearer lines of responsibility at both national and local levels – for example, to avoid some of the problems UNISON branches experienced with holding STPs to account
  • Expectation of full partnership working throughout any transitional processes
  • Ensuring that any changes do not reduce any gains made in recent years in terms of union access to decision-making bodies
  • Proposals should ensure parity of esteem for mental health and community services
  • The need to raise the funding, profile and status of social care if meaningful integration between sectors is to be a realistic aim

Please let us have any feedback or thoughts on these principles by emailing policy officer Guy Collis at by 5 January 2021.