Our response to the NHS England Integrated Care System consultation
Next steps to building strong and effective integrated care systems across England (January 2021).
Next steps to building strong and effective integrated care systems across England (January 2021).
We have responded to an NHS consultation on building integrated care systems across England. We are calling for enhanced eye care services to be commissioned at integrated care system level, but primary eye care service (GOS) commissioning should remain national and not delegated to ICS bodies. We strongly recommend that commissioners include optometrists and other eye care professionals in the planning of more integrated services. Read more about the consultation.
Despite being effectively mandated by NHS England and NHS Improvement (NHSEI), ICSs are currently voluntary partnerships, as they have no basis in legislation and no formal powers or accountabilities. ICSs cover large geographical areas so it is important to give them the right statutory basis to effectively design and deliver services that meet the needs of their local populations.
Furthermore, the design and implementation of ICSs are currently being locally led. While this approach builds on the ICSs’ existing local relationships, there is uncertainty around what the final structures will be, and this localised approach may create unwarranted variation across the country. We believe that appropriate legislative changes that incorporate the required operating, governance and decision-making arrangements will help strike a balance between providing sufficient clarity on the core functions and responsibilities of ICSs and enabling flexibility to adapt to local needs.
There are already examples of rapid progress being made in transforming eye care models locally so that they join up primary and secondary care, involve collaborative, multidisciplinary clinical leadership, champion digital connectivity and meet local patient needs. For example, through implementing primary care-based COVID-19 urgent eye care services (CUES) and the National Ophthalmology Transformation Programme (NOTP)1. It is essential that, where joined up patient-centred care is working well, it is allowed to continue and that the outcomes and learning from these examples shape the next stages in the development of collaborative place-based care.
We welcome the proposals to merge CCGs to cover larger areas under an ICS structure. This should help address regional inequalities by commissioning enhanced eye care services for larger populations, which we have long called for. Commissioning at ICS level would enable the provision of consistent, coordinated eye health services across primary and secondary care, in settings appropriate to the patient’s clinical risk; making best use of available expertise and resources, whilst avoiding waste and duplication and delays for care. This in turn could support implementation of the National Ophthalmology Transformation Programme and facilitate the reform of ophthalmology by expanding capacity to meet growing need, whilst freeing up hospital eye services for patients with genuinely acute needs, as set out in the NHS Long Term Plan.
We are therefore calling for enhanced eye care and sight loss services to be co-ordinated and commissioned at ICS level, so planning and provision of services can work across whole pathways and over traditional service footprints, to support the delivery of efficiencies and transformation at scale. However, while we welcome NHS England/Improvement’s concern about the implications of legislating to abolish CCGs, it is not clear whether this could be achieved without another wholesale structural reorganisation, distracting commissioners, managers and health professionals from achieving their core mission.
1. The NOTP is bringing together clinicians, commissioners, managers, patients and professional organisations to define immediate priorities for the restoration of outpatient services across primary, secondary and community care. Guidance, practical tools, resources and active support will enable local systems to restore outpatient services safely. The collaborative will also identify and consider systemic barriers to the transformation of outpatient services, working across boundaries to overcome these. Strengthening the capability of the system, exploiting technology and designing flexible delivery models will create a sustainable, safe, integrated and patient focused system.
However, the lack of detail underpinning both legislative options leaves several questions unanswered.
As mentioned in our response to question 1, placing ICSs on a statutory footing should provide greater transparency and accountability. There is a need to establish both the legislative basis for the responsibilities and accountability of ICSs and consistent processes for governance and reporting on service implementation, quality and outcomes at ICS level.
As there is no specific legislation governing how ICSs currently operate, progress to date has been made by local leaders working around the current legal framework, making use of flexibilities such as the ability to form joint committees across organisations. The problem with these workarounds is that they are complex and risk being unstable if partner organisations disagree.
Having a statutory ICS body would allow clearer responsibility for regular scrutiny and review of the impact of health services (and their related budgets) at scale over a broader geographic or population footprint. NHS England/Improvement should have powers to encourage and facilitate collaboration but also powers to prevent structural changes that could work against the interests of patients – for instance, where the result will be reduced access to eye healthcare in primary and community settings.
It would be useful to introduce more consistent and clear mechanisms for public accountability and engagement between ICSs, as this would add clarity for both regulators and service users.
Many unanswered questions remain to understand how the voices and priorities of service users can be most effectively and meaningfully included within the governance and decision-making of ICSs, and how staff at all levels will be supported to effectively collaborate across organisational and professional boundaries. We would recommend clarifying the powers an ICS will have in relation to local NHS organisations, particularly trusts, and how either model will be structured to enable mutual support between provider organisations and effective co-operation within sectors.
It would enable a more flexible collaboration. It is important in a fast-changing world that ICSs are able to be flexible and responsive to change.
However, it is vital that all primary care providers, including primary eye care, are mandated to be involved in the design, delivery and leadership of more integrated services for local populations. ICSs and commissioners should work closely with NHS England’s Local Eye Health networks (LEHNs) and Local Optical Committees (LOCs) to facilitate integrated eye care services in primary and community settings. Eye care has not been integrated into current Primary Care Networks, and so involvement must be actively sought. There cannot be an assumption that representation from a Primary Care Network will effectively represent all pillars of primary care (i.e. that a PCN includes eye care, dentistry and pharmacy).
Therefore, we strongly recommend that commissioners include optometrists and other eye care professionals – not just GPs – in the planning of new integrated services, as well as their delivery. This will help ensure that new services are designed around the real needs of patients, which will include growing eye healthcare capacity for an ageing population.
Primary care optometrists can help commissioners maximise the scope for NHS primary care providers to deliver additional eye healthcare capacity in accessible locations, rather than relying on overstretched hospital eye services – thus supporting the delivery of out of hospital services in local communities, as recommended in the NHS Long Term Plan. This would also be compatible with the current National Ophthalmology Transformation Programme (NOTP) work led by NHS England/Improvement.
We also recommend that new funding to support joint working within primary care is distributed fairly to those involved, and not directed only to GP practices.
There should be minimum national standards to ensure this representation for primary care, with additional local flexibility to allow systems to fine-tune their governance arrangements. These national standards should cover the following points:
The General Ophthalmic Services (GOS) currently commissioned by NHS England provide over 13 million NHS sight tests in primary and domiciliary settings each year. These services are delivered by the majority of primary care optical practices in England, which provides a standardised and equitable eye healthcare offer across the country. Our priority is to ensure that patients continue to receive a high quality and clinically robust service every time they visit their optometrist, which is why we do not support the transfer of GOS commissioning to ICSs.
We strongly recommend that commissioning of primary eye care services remains national. This will ensure that equal access to and benefit from a standardised primary eye healthcare offer continues across the population. CCG commissioning has been too fragmented to date.
In 2019-2020, 13.3 million people in England were seen under GOS (NHS Digital: General Ophthalmic Services Activity Statistics England, year ending 31 March 2020). These services are clearly and narrowly defined and form a high quality national service, which is delivered in readily accessible high street locations by thousands of optical practices, while increasingly integrated with GPs and secondary care. Moving to local commissioning could create unwarranted variation in access to core primary eye care services, and could reduce provision in some areas, damaging patient care. It is not clear how the delegation of functions (and budgets, in some cases) to the level of ICS would be supported in practice. We are also concerned that a localised GOS budget could be spent before the end of a budget year, which could lead to free eye tests being unavailable for some of the population most at risk of sight loss or vision problems.
The GOS system is driven by patients being able to access the eye care provider of their choice, in whichever convenient location they choose, thus guaranteeing access for all eligible patients and a standardised service (set out in primary legislation), irrespective of where people live. This patients’ rights to choice should be protected.
Furthermore, the eye care sector has long recognised the benefit of, and been calling for, the strengthening of enhanced primary eye care services. To date these have been locally commissioned by CCGs, resulting in inconsistently available and fragmented services. Consistent commissioning of enhanced primary eye care services at ICS, multi-ICS or regional level, rather than at CCG level, would reduce duplication and unwarranted variation, support transformation of hospital eye services, relieve pressure on A&E and GPs, and provide patient choice.
There is little information on how ICSs will make best use of and contribute to the development of both data and workforce planning. We have set out below why both are important areas to include in the ICS mandate.
Better quality data across eye care pathways is essential. Commissioners cannot make strategic decisions on eye care or properly understand its importance when they have too little data. This crucial evidence will help commissioners understand local demand for eye care and identify any unmet need. Without high quality data, developing innovative approaches to preventing sight loss will be severely hampered.
We need to have an accurate understanding of the population’s needs the system is trying to meet in order to plan effective and appropriate eye care services. For example as a first step, the existing data in the General Ophthalmic Services payments systems and hospital clinical systems needs to be collated and used to best inform ICS planning and commissioning. We would then like to see a move towards better quality and more comprehensive data collection at ICS level, which can be used to inform both local (ICS/enhanced primary care) and national (GOS) primary care service provision.
It is important to understand how ICSs will be expected to take a role in workforce planning and development to ensure safe and effective services for patients that make best use of local healthcare professionals. There is the need of a clearer requirement for ICS to identify workforce gaps and work with partners to make appropriate plans to support the training and development of all staff who deliver commissioned services.
For example, pressures on hospital eye departments are immense and growing. Harmful delays to treatment in the hospital eye service were recognised before the pandemic. We need to offer new models of care if we are to avoid unnecessary sight loss and meet growing patient needs. Optimising all available skills across eye health professionals and ensuring trust between primary and secondary care are key in delivering these new models of care. Optometrists are ready and well positioned to play a wider role in transforming eye health delivery alongside other health professionals.
Primary care optometrists are well-placed to provide enhanced and shared care services closer to home and to reduce the backlog of delayed outpatient appointments through both referral refinement and autonomous management of certain eye conditions, without additional training. Many optometrists also have higher and independent prescribing qualifications that enable them to provide autonomous diagnosis and management of low- and suitable medium-risk patients alongside secondary care clinicians. These skills should be recognised and utilised.
Primary care optometrists should be involved locally in co-developing and leading the workforce planning required for effective care pathways. Where there are common development or training areas across primary care pathways e.g. governance, audit, service evaluation, it would make best sense for this training to be made available to all primary care professionals, including optometrists.
Submitted: January 2021