Whilst competition can drive service improvement, it has in some cases hindered integration between providers Currently, the Competition and Markets Authority ( CMA) has specific powers to review mergers involving foundation trusts ( FTs). It has become clear that the CMA is not the right body to review NHS mergers. In line with NHS England’s recommendations, we intend to remove these powers and allow NHS England, as overseer of the system, to ensure that decisions can always be made in the best interests of patients. The CMA’s jurisdiction over mergers is UK-wide, so we are working with the devolved administrations to ensure there would be no unintended consequences of these proposals. This white paper represents a significant milestone on the journey towards achieving our objective of supporting everyone to live healthier and fulfilling lives for longer. COVID-19. COVID will continue to cause innumerable short, medium and long-term effects to healthcare in the UK and has shone a spotlight on inequalities We are also bringing forward several measures to improve accountability in the system in a way that will empower organisations and give the public the confidence that they are receiving the best care from their health and care system, every time they interact with it. The de facto development in recent years of a strongly supportive national NHS body in the form of a merged NHS England and NHS Improvement will be placed on a statutory footing and will be designated as NHS England. This will be complemented by enhanced powers of direction for the government over the newly merged body which will support great collaboration, information sharing and aligned responsibility and accountability. In addition, we will legislate to further ensure the NHS is able to respond to changes and external challenges with agility as needed. Measures will include reforms to the mandate to NHS England to allow for more flexibility of timing; the power to transfer functions between arm’s length bodies and the removal of time limits on special health authorities. An improved level of accountability will also be introduced within social care, with a new assurance framework allowing greater oversight of local authority delivery of care, and improved data collection allowing us to better understand capacity and risk in the social care system. Our measures recognise this, and we therefore plan to introduce greater clarity in the responsibility for workforce planning and a clear line of accountability for service reconfigurations with a power for ministers to determine service reconfigurations earlier in the process than is presently possible. Additional measures require health and adult social care organisations to share anonymised information that they hold where such sharing would benefit the health and social care system

We are proposing to establish statutory ICSs, made up of an ICS NHS Body and an ICS Health and Care Partnership (together referred to as the ICS), to strengthen the decision-making authority of the system leadership and to embed accountability for system performance into the NHS accountability structure. This dual structure recognises that there are 2 forms of integration which will be underpinned by the legislation: the integration within the NHS to remove some of the cumbersome barriers to collaboration and to make working together across the NHS an organising principle; and the integration between the NHS and others, principally local authorities, to deliver improved outcomes to health and wellbeing for local people. enable NHS England to delegate or transfer the commissioning of certain specialised services to ICSs singly or jointly, or for NHS England to jointly commission these services with ICSs if these functions are considered suitable for delegation or joint commissioning subject to certain safeguards. Specialised commissioning policy and service specifications will continue to be led at a national level ensuring patients have equal access to services across the country We anticipate that there will continue to be an important role for voluntary and independent sector providers, but we want to ensure that, where there is no value in running a competitive procurement process, services can be arranged with the most appropriate provider. The NHS will continue to be free at the point of care and our proposals seek to ensure that where a service can only be provided by an NHS provider – for example, A&E provision – that this process is as streamlined as possible. We intend this collaboration proposal to replace 2 existing duties to cooperate in legislation to support our wider ICS policy, where we expect local authorities and NHS bodies to work together under one system umbrella. Triple aimNHS activity has grown every year since records began (at an average of 3.3% a year). Over the last 9 years (between 2009/10 and 2018/19) the number of attendances in A&E increased by 4.3 million; the number of GP appointments have risen from 222 million in 1995 to 308 million in 2018/19; and the number of outpatient attendances has increased by almost 36 million since 2009/10 Furthermore, the pandemic has highlighted the need to balance national action with local autonomy. The evolution of the system in recent years has led to greater level of responsibility being held by NHS England and NHS Improvement. As integrated care systems are established, we expect more of that responsibility to be held by ICSs themselves. This will be accompanied by measures to strengthen and clarify the role of government and Parliament. The Department will also have a critical role to play in overseeing the health and care system and in ensuring strong alignment and close working between public health, healthcare and social care. The ICS will also have to work closely with local Health and Wellbeing Boards (HWB) as they have the experience as ‘place-based’ planners, and the ICS NHS Body will be required to have regard to the Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies that are being produced at HWB level (and vice-versa). ICSs will also want to think about how they can align their allocation functions with place, for example through joint committees, though we are leaving this to local determination. NHS Trusts and Foundation Trusts ( FTs) will remain separate statutory bodies with their functions and duties broadly as they are in the current legislation. It will also support the Secretary of State to set clear direction in a more agile way, and to do so formally alongside the strong and effective informal arrangements for working together that have evolved between the Department and NHS England in recent years.

NHS Long Term Plan confirmed that every area will be served by an integrated care system by 2021, with primary and community services funded to do moreremove NHS Improvement’s specific competition functions and its general duty to prevent anti-competitive behaviour The public largely see the NHS as a single organisation and as local health systems work more closely together, the same needs to happen at a national level. Recognising the evolution of NHS England, we are also bringing forward a complementary proposal to ensure the Secretary of State for Health and Social Care has appropriate intervention powers with respect to relevant functions of NHS England. This will support the Secretary of State, when appropriate, to make structured interventions to set clear direction, support system accountability and agility, and also enable the government to support NHS England to align its work effectively with wider priorities for health and social care. This will serve, in turn, to reinforce the accountability to Parliament of the Secretary of State and government for the NHS and the wider health and care system.

The set of proposals relating to the National Tariff are intended to implement NHS England’s recommendations and update the legislative requirements to reflect and support the drive towards greater integration in healthcare; make adjustments that remove barriers to desired pricing approaches; and simplify and streamline the pricing process. Experiences during the pandemic have also demonstrated the positive impact that financial frameworks can have on facilitating joint working. introduce a power for the Secretary of State for Health and Social Care to mandate standards for how data is collected and stored, so that data flows through the system in a usable way, and that when it is accessed/provided (for whatever purpose), it is in a standard form, both readable by, and consistently meaningful to the user/recipient remove the need for NHS England to refer contested licence conditions or National Tariff provisions to the CMA Our ICS NHS body provisions go most of the way to increasing the ease with which providers and commissioners could establish joint working arrangements and support the effective implementation of integrated care. We consider, nonetheless, that NHS England’s recommendation to allow ICSs and NHS providers to create joint committees would be a useful addition, removing unnecessary barriers to joined-up decision making.This proposal will not impact on Parliament’s ability to scrutinise the mandate – each new mandate will continue to be laid in Parliament by the Secretary of State and will be published. NHS mandate requirements will also continue to be underpinned by negative resolution regulations, providing further opportunity for Parliament to engage with the content of the mandate. Furthermore, the existing duty for the Secretary of State to consult NHS England, Healthwatch England, and any other persons they consider appropriate before setting objectives in a mandate, will also remain in place. Healthwatch England’s involvement ensures that all NHS mandates are informed by the needs of patients and the public. Reconfigurations intervention power To further support integration, we propose to implement NHS England’s recommendation for a shared duty that requires NHS organisations that plan services across a system ( ICSs) and nationally (NHS England), and NHS providers of care (NHS Trusts and FTs) to have regard to the ‘triple aim’ of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.

The reforms within these legislative proposals will remove the current procurement rules which apply for NHS and public health commissioners when arranging healthcare services. They will do this by creating the powers to remove the commissioning of these services from the scope of the Public Contracts Regulations 2015, as well as repealing Section 75 of the Health and Social Care Act 2012 and the Procurement, Patient Choice and Competition Regulations 2013. NHS England response to the ICS consultation document and the government brings forward legislative proposals to support integration These powers will not allow Secretary of State to direct local NHS organisations directly nor will they allow the Secretary of State to intervene in individual clinical decisions. They will also not undermine the established NICE process and guidance for treatments and medicines. The NHS mandate Additional consequential changes will also be made to the current legal provisions on integration (the Better Care Fund) which currently rely on the NHS mandate. These provisions will be recreated as a standalone power so that they will continue to meet the policy intention for the Better Care Fund even where mandates are not replaced annually. We also recognise that the social care system needs reform: this remains a manifesto commitment and the government intends to bring forward separate proposals on social care reform later this year. No one piece of legislation can fix all the challenges facing health and social care – nor should it try – but it will play an important role in meeting the longer-term health and social care challenges we face as a society.Despite the success of NHS England and NHS Improvement’s joint working programme, there are limits to how far they can fully collaborate under the current legislation. For example, both organisations have separately been assigned some distinctive and non-shareable functions in legislation – they are currently required to have separate Boards, Chairs, CEOs and non-executive directors and still consist of 3 separate employers. Despite the efforts of both organisations to find practical arrangements and ‘work-arounds’, these restrictions and governance arrangements prevent the organisations from fully operating as one single organisation. While LETBs operate only in England, we will work with devolved administrations should this proposal have any UK-wide impact. We are not seeking to significantly alter the provider landscape; however, NHS England’s recommendations to government included a provision to allow the creation of new trusts for the purposes of providing integrated care. We agree that there may be merit in creating a new trust to provide integrated care, and there may also be other circumstances when the Secretary of State may want to create a new trust. Consequently, we intend to allow the creation of new NHS trusts with the overriding objective of ensuring the health system is structured to deliver the best outcomes for whole population health and respond to emerging priorities. This is in line with our overarching aim to ensure the system is flexible and adaptable into the future, and wherever possible avoids the need for complex workarounds to deliver system priorities.