ICBs are a ‘sensible management structure’ in theory, but tensions exist between system leaders and providers which it is ‘essential’ to resolve, the independent investigation into the NHS by Lord Darzi has concluded.
The Government commissioned cancer surgeon and former Labour minister, Lord Ara Darzi, to lead an investigation into the state of the NHS, which will feed into its 10-year plan for the health service.
In his 160-page report, published today, Lord Darzi suggested that there was an ‘ambiguity’ in the relationship between providers and ICBs, with ICBs differing in opinion on how far they are responsible for performance management of providers.
He added there were duplications of functions between the two, such as infection prevention and control, and where trust boards should be held accountable.
He recommended that more consistency was needed, especially given the scale of the ‘performance challenge’.
The report said: ‘The function and authority of ICBs remains unclear in some important respects. The 2023 Hewitt Review was unable to clearly define the relationship between providers and ICBs, and the ambiguity persists.
‘More consistency is now needed in the way ICBs are organised and their functions should be more standardised.’
He added: ‘There are some important ways in which the performance management framework needs to change, in particular to clarify the role of ICBs with regards to provider trusts. Given the scale of the performance challenge, it will be essential that this is resolved at pace.’
Critical condition
Lord Darzi’s eight-week investigation looked at the state of the NHS, concluding that it was in a ‘critical condition’.
It found that the NHS was in this ‘dire state’ following a decade of austerity, being ‘starved’ of capital investment and the impact of the Covid pandemic.
He also stated that management structures and systems were ‘reeling from a turbulent decade’ and the growth in oversight.
He said: ‘The Health and Social Care Act of 2012 was a calamity without international precedent. It proved disastrous. By dissolving the NHS management line, it took a “scorched earth” approach to health reform, the effects of which are still felt to this day. It has taken more than 10 years to get back to a sensible structure. And management capability is still behind where it was in 2011.’
Defining population health
Lord Darzi also cited other issues facing systems, including that ICSs have found it challenging to fulfil their aims on population health.
He said: ‘In the call for evidence, we heard conflicting accounts of the definition of population health and the ways in which ICBs interpret their duty to improve it. NHS England has aimed not to be prescriptive in the way in which ICBs have formed and how they fulfil their aims.’
While some have interpreted it as acting on the social determinants of health, others are working towards adjusting healthcare services to match the needs of the population they serve.
‘Some interpret it as both and others as neither, preferring to focus on what they see as their “traditional” role of performance managing providers,’ he added.
Though some have called for a reduction in managers within the NHS, Lord Darzi said this was not a problem. Instead, he said there were ‘too few’ with the right skills and capabilities.
‘International comparisons of management spend show that the NHS spends less than other systems,’ he said.
‘This has often been observed as a source of pride; but it may well be a failing, since it suggests that the NHS is not employing enough people whose primary responsibility is that its resources are used well, and the talents of its clinicians are focused on delivering high quality care. We need to invest in developing managerial talent and creating the conditions for success.’
He added that while there are some examples of ‘brilliant integrated care’ across the country, that there has yet to be a ‘systematic shift at scale’.
‘Indeed, the more the NHS has talked about integration, the less satisfied patients have become with the coordination of their care,’ he said, adding that ‘including “integrated care” in the title of organisations does not make it thus’.
He brought out seven themes on ‘how to repair the NHS’, including to:
- Re-engage staff and re-empower patients,
- Lock in the shift of care closer to home by hardwiring financial flows,
- Simplify and innovate care delivery for a neighbourhood NHS,
- Drive productivity in hospitals,
- Tilt towards technology,
- Contribute to the nation’s prosperity,
- Reform to make the structure deliver.
It concluded: ‘Many of the solutions can be found in parts of the NHS today. The vast array of good practice that already exists in the health service should be the starting point for the plan to reform it. The NHS is a wonderful and precious institution. And no matter the challenges it faces, I am convinced it can return to peak performance once again.’
In response to the report, Sarah Woolnough, chief executive of The King’s Fund, said: ‘Lord Darzi’s report underscores the need to move beyond past lazy criticism of the value of NHS managers and instead recognise that implementing major improvement of the health service requires investment in high quality leaders.
‘Ministers now face tough trade-offs between tackling immediate NHS pressures, or prioritising reform of the root causes of the crisis. Today’s report makes clear that incremental improvement will not do – radical change is needed.
‘The task is not simply to prop the NHS back up, it is to create a new approach to health and care in this country.’
Sir Julian Hartley, chief executive of NHS Providers, said: ‘Lord Darzi’s report acknowledges what trust leaders have long called for – if we want to improve patient care and boost productivity, we need significantly more capital investment in the NHS alongside wider reforms including a shift to providing more care closer to home.
‘Old, crumbling buildings, facilities, and equipment well past their sell-by date hamper care for patients. Much of the NHS estate is in a bad way. We need modern, safe places where staff can give patients first-class care in hospitals, mental health, community and ambulance services, and tackle the £11bn-plus bill for essential repairs waiting to be done. We can’t afford to let this problem get worse.
‘Trust leaders and their teams, working flat out to cut waiting lists and see patients as quickly as possible, need long-term investment to ease pressure, meet demand and step up productivity – all of which can help to raise the quality of care for patients.
‘A healthy NHS is vital for the nation’s health and wellbeing.’
Dr Jennifer Dixon, chief executive of the Health Foundation, added: ‘The main focus of Darzi’s report is on the NHS, but it also – rightly – points to the fact that the nation’s health is fraying. Improvements in life expectancy have stalled, more people are living with preventable health conditions and deep inequalities in the nation’s health are widening. Cuts in local public health budgets, political neglect of social care, and weak investment in wider public services that shape our health have made things worse.
‘The question now is what the government does in response. Darzi’s diagnosis points to some obvious priorities for NHS reform, including shifting the balance of resources towards primary care and community-based services, modernising NHS buildings and equipment, and harnessing the benefits of new technology to improve care for patients. The NHS is weakened but not broken – and staff can recover services if they are given the resources to make it happen.
‘But ministers must go further and use their health ‘mission’ to put health at the heart of government and take coordinated action across Whitehall on the building blocks of health – like income, employment, and housing.’
Professor Nora Colton, director of global business school for health, said: ‘This review is a really important piece of work. It is right to focus on the essential role of leadership and call for a reverse in the underinvestment in NHS managers that has gone on for far too long.
‘Responding to the complex, multidisciplinary care needs of the population requires leaders with exceptional skill sets that require time and investment to develop properly. That’s why we need a fresh approach and leadership which brings together the best of business and clinical expertise.
‘A well-managed workforce is critical to all the recommendations in the report, and it’s time to put good leadership at the heart of NHS performance.’
Nuffield Trust CEO, Thea Stein, added: ‘Ultimately, the Lord Darzi’s diagnostic report sets out important aspirations to be delivered in the forthcoming 10-year plan to treat – and fix – the NHS. But the improvements we all hope for – and that patients desperately need – will take time, commitment and major financial, practical and system-wide support. There will be no quick fixes.’
