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The health-hub of tomorrow: opportunities for integration and co-location in the new governance of ICBs

Introduction
Integrated Care Boards (ICBs) came into being on 1 July 2022, replacing CCGs and taking on formal commissioning responsibilities. These changes are in line with the Health and Social Care Act 2022.

Helen Simmonds
Helen Simmonds

The introduction of a single budget and single commissioning function is significant, and many of the intended benefits have already been well-reported on. One area which has been talked of less in the media is the potential for and opportunity created by ICB-owned and / or controlled clinical estate assets.

Relatedly, the recently published ‘next steps for integrating primary care’: Fuller stocktake report emphasised the need for local decision making in primary care, including enabling service transformation through a fit for purpose clinical estate. This report sets out to explore the opportunities set out by these two landmark publications.

Background
If the hope is that the Act and the Fuller stocktake report will result in a more coordinated approach to preventing illness and improving health outcomes by working across primary, community and secondary sectors, then we must be aware of the of the current barriers that already restrict this and consider ways in which ICB formation can help overcome them. They can be considered to fall into one of three broad categories:

  • Legal – relating to estate ownership and restrictive lease agreements which underpin flexible occupation;
  • Operational – relating to the size, physical quality, and accessibility of the estate across a given geography;
  • Cultural – historic ‘siloed’ ways of working across organisations and between primary and secondary care, crystalised by separate budgets, ever more challenging workload pressures and even differing models of employment.

Legal barriers

It’s important to remember that general practices are private businesses.  Their contract requires them to find, secure and take on the liability of the premises from which to deliver medical services (either as an owner-occupier, or the rental liability associated with a lease).  Rents are reimbursed, but the issue of perceived and veritable estate liability is a growing challenge for GP recruitment[1].  Layer onto that an expectation that practices will deliver increasing numbers of out-of-hospital and out-of-hours services – as the Fuller stocktake report promotes – and the problem risks being compounded. 

Similarly, long-lease terms with restricted nomination and occupation rights, a necessity currently to satisfy landlords and shareholders that they will get a return on their investment, do little to facilitate integrated working and flexible service co-location.  For population health management to make the most significant impact, service delivery and commissioning need to be agile, responding to and even pre-empting changing local health and socio-economic issues at pace.  The current system of occupation is onerous and inflexible, locking some providers into spaces for decades, and excluding others who cannot commit to such long period of time (for example, third sector or charity organisations).

But this doesn’t need to be the way.  Until now, commissioners of primary care services – CCGs – have been unable (in policy terms) to take on the liability for clinical estate assets.  ICBs on the other hand have no such restriction.  The potential therefore is ICB-owned or -wholly-controlled assets to help overcome the identified legal barriers above and usher in new approaches to flexible working and the rotation of services from a given asset to mirror  population health needs as set out in the Fuller stocktake report.

Operational barriers
The second category – labelled here as operational barriers – has long been understood.  32% of the entire estate pre-dates 1974[2], and in 2019/20 there was £9.7bn of backlog maintenance – nearly double the NHS’s £4.9bn share of the capital departmental expenditure limit (CDEL) in that year[3].  The 2019 GP Premises Review revealed that at least 40% of the entire GP primary care estate – approximately 3,500 buildings – is self-identified as being either not fit for current or future service needs.  The implication, therefore, is that this estate cannot deliver on the ambitions of the NHS Long Term Plan or the 2022 Fuller stocktake report, including the left-shift of services out of an acute setting and more focus on preventive services.

There have been attempts to improve this.  The NHS LIFT programme (2001 – 2014) delivered more than 330 high-quality clinical assets through public-private finance initiatives in some of the country’s most deprived communities, whilst the Estates and Technology Transformation Fund (ETTF) invested more than £800m of public money into primary care infrastructure[4].  But we know there is still a long way to go. 

The formation of ICBs opens opportunities to build on these achievements and provides an impetus to redouble our efforts in lobbing for a renewed round of capital expenditure focussed on the delivery of genuinely public, community-based assets that serve as anchor institutions with all the associated understood benefits of these[5].  The co-location of multiple GP practices into appropriately sized new- or reconfigured-centres – united by a PCN population list, for instance – and complimented by a range of non-clinical, prevention-focused services helps to reduce duplication across a footprint and maximise the return on investment to the public purse for every £1 spent and be considered to support a number of the recommendations set out in Dr Claire Fuller’s report.

Many of the problems we face today in terms of operational barriers is because the buildings were built with too-narrow a healthcare function in mind, or not for healthcare use at all (e.g. converted houses).  Any new or reconfigured clinical assets should follow the watchword of ‘long-life, loose-fit’; buildings which can respond to the ever-changing needs of population health, planning for the changes we know are coming – but having enough foresight and maturity to acknowledge our ignorance of the healthcare needs of future generations.

The opportunity of cultural change
The third category – ‘cultural’ – covers mindset and ways of working which have, inevitably, been historically influenced by the circumstances surrounding the other two categories and the NHS organisation structure, funding and governance.  An NHS which sets internal organisational targets and rewards, rather than wider systemic ones, is an NHS that (inadvertently) fuels siloed working and stifles strategic, early intervention. Amongst the myriad of excellent case studies and examples, these systemic issues were brought to the fore in the Fuller stocktake report and identified as stifling innovation and transformation across primary care.

The ‘cultural’ category is linked to politics, too, and the need for parity of funding of primary care estate and workforce. We have known for a long time, for instance, the burden of preventable disease on the NHS[6], both financial and otherwise, and the benefits of early prevention and targeted interventions that take into consideration a patient’s wider social determinants of health.  Countries who have addressed this head-on have done so with impressive population health outcomes[7].  Yet here in England we continue to put disproportionate emphasis on hospitals as the centre of the of the health economy and continue to prioritise investment on acute sites rather than in the community (maybe, in part, because it’s easier to do so into NHS-owned assets rather than addressing the complications of primary care estate ownership – full circle to ‘legal’ and ‘operational’ categories above…).

The Fuller stocktake report articulates exactly this issue. 90% of patient interaction occurs in  primary care, yet general practice only receives approximately 8%[8] of the NHS budget. It recognises that we must move to a model that makes estates a catalyst for integration rather than a barrier to it. This new model should focus on patient needs, create a positive working environment for staff and provide adequate space for key activities like training and team development.

ICBs have the potential to change this.  Where it can (has been) be proven that investing ‘upstream’ can save cash, time and human resource, then surely new single-budget commissioners will – hopefully – look to pull all the levers necessary to make this happen for their own good as well as the populations they serve.  In governance terms, they have been set up to practice what they preach; representatives from PCNs as well as acute sites will sit on the board and collectively decide where and how to invest their limited capital allocations.  This should bode well for primary care; all 42 ICB CEO-designates endorsed Dr Claire Fuller’s report. Scrutiny should be applied to existing and proposed estates solutions, challenging and questioning whether the right services are really being delivered in the right place.  ICBs present the opportunity to think ‘beyond’ the limitations of ownership (and even employer) to achieve this across not just the NHS, but public property more widely.

Conclusion
It is early days and many uncertainties remain pertaining to the effectiveness and subsequent reaction to England’s 42 new, place-based health commissioners.  What this brave new world will look like for primary care commissioning and estates in the future remains to be seen. But the alignment, both in sentiment and timing of the Act and the Fuller stocktake report is encouraging. 

I for one hope that ICBs usher in a new, better balanced health economy that places greater emphasis on community assets and the role of prevention.  Now we just need to get on and build them.


[1] As identified in the GP partnership review (published January 2019) and the general practice premises policy review (published June 2019).

[2] NHS property and estates: Naylor review (published March 2017)

[3] NHS Providers blog (January 2021): The growing maintenance backlog across the NHS estate

[4] The return on investment for the public purse for the ETTF programme was thought to be as little as 40pence for every £1 invested – i.e. a 60% deficit

[5] Building healthier communities: the role of the NHS as an anchor institution (published by the Health Foundation in August 2019)

[6] Fair Society, Healthy Lives (The Marmot Review) (published 2010)

[7] Israel

[8] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/funding/investment-in-general-practice

Last Updated on 30 September 2022