• Near final version of white paper confirms plans to strengthen DHSC powers over NHS England and local reconfigurations.
  • “Autonomy” of providers is reasserted, and funding/providing of services remains separate.

The health secretary is due to publish its final white paper proposals, widely trailed then leaked last week, later on Thursday. I refer you to https://digital.nhs.uk/services/organisation-data-service/change-summary—stp-reconfiguration

A near-final version of the Department of Health and Social Care’s proposals shows it is pressing on with measures including allowing the health secretary to intervene in local service reconfiguration and to direct and dissolve arm’s lengths bodies; creating a two-part integrated care system model; removing competition rules and regulation; merging NHS England and Improvement, and giving government much stronger powers over the new NHS England.

It says its “proposals for health and care reform will start to be implemented in 2022” and indicates that NHS England and NHS Improvement will be formally merged in 2022. But it does not specify a date for the formal creation of integrated care systems and dissolution of clinical commissioning groups.

However, the near-final version of the white paper includes some notable tweaks from the draft, seeking to head off concerns from some quarters.

The amendments include:

  • Indicating that integrated care systems must be “coterminous with local authorities” – which would mean that, unless exemptions are created, established ICSs such as Frimley Health (which covers one unitary authority and chunks of two counties), and the three which cover different parts of Essex County Council, may need to be split up or redrawn.
  • Rewording the health secretary’s new powers over NHSE (see box below) and stating that, where the health secretary intervenes in specific service reconfigurations, he, or she “will be required to seek appropriate advice in advance of their decision, including in relation to value for money, and subsequently publish it in a transparent manner”.
  • Emphasising foundation trust independence, which some fear is undermined by the proposals. It says an ICS board “will not have the power to direct providers” and that a “reserve” power to set “legally binding” capital expenditure limits FTs was “not a general power to direct all FTs on capital spending [or] erode FT autonomy”. Details of how the power would be used transparently have been removed, however.
  • Highlighting that “there is a real chance to strengthen and assess patient voice at place and system levels, not just as a commentary on services but as a source of genuine co-production”, citing Healthwatch in particular.
  • Stressing that provision of NHS services will remain separate from planning and funding them – not completely collapsing the purchaser/provider split: “These changes retain a division of responsibility between strategic planning and funding decisions on the one hand, and care delivery on the other, but allow for its operation in a more joined up way. We will preserve the division between funding decisions and provisions of care.”
  • Recognising local authority budget concerns – stating that changes to NHS Continuing Healthcare to enable “discharge to assess” will not “increase financial burdens on local authorities” – which may frustrate NHS bodies looking to speed discharges.
  • On specialist commissioning the legislation has changed to ensure financial delegation is “subject to certain safeguards” with quality outcomes still overseen at a national level to ensure patients “have equal access to services across the country.”
  • Specifying that ICS will have a “unitary” board, akin to current foundation trusts, with a mixture of non-executive and executive directors sharing responsibility; and that NHSE will publish guidance on the makeup of the boards “including how chairs and representatives should be appointed”.

Powers over NHS England

The leaked draft said there was a need for “a clear and strengthened democratic oversight and clarity for decision making throughout the system [so we are] proposing to create a power of direction over NHS England”, and claimed: “Covid has reinforced the importance of and increased need for clear and unified lines of accountability from the front-line to parliament.”

But the near-final version does not refer to the covid pandemic in relation to the new powers, and introduces different wording, stating: “We are bringing forward a complementary proposal to ensure the secretary of state has appropriate intervention powers with respect to NHS England.

“This will maintain clinical and day to day operational independence for the NHS but will support accountability by allowing the [health secretary] to formally direct NHS England in relation to relevant functions.”

It says: “The public and patients need to know that when issues arise, and when people need answers to their concerns, there are systems in place to address the issues at the appropriate level.

That is likely to almost always be done within systems rather than at a national level. However, there will be occasions when it will be necessary for national leadership and for NHS England to set direction. Equally, there will be occasions when it is appropriate for ministers to take more oversight in relation to NHS England., and these proposed powers would structure such interventions and ensure ministers are accountable for them.”

In relation to powers for the health secretary to remove powers from, or abolish, any health arm’s length body, the near-final version of the white paper asserts that these “will also not undermine the established NICE process and guidance for treatments and medicines”.


DHSC white paper: “Integration and Innovation: working together to improve health and social care for all”