NHS 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 make changes to NHS Digital’s legal framework to introduce a duty on NHS Digital to have regard to the benefit to the health and social care system of sharing data that it holds when exercising its functions; and clarify the purposes for which it can use data Existing ICS arrangements are based on voluntary arrangements, rather than legislative provision, and are therefore dependent on goodwill and mutual co-operation. There are also legislative constraints on the ability of organisations within an ICS to make decisions jointly. While several systems have found ways to establish effective governance models, there are some obstacles and limitations in the current legal framework which inhibit this. For example, there is no legal basis at present for clinical commissioning groups ( CCGs), NHS trusts and foundation trusts ( FTs) to form a joint committee to which functions may be delegated, with the power to make decisions on behalf of the organisations within the ICS.

Quality of care improvements. As of 2020, around 94% of GP practices rated good or outstanding by the Care Quality Commission (CQC), around 82% for NHS mental health core services and 85% of adult social care providersenable 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 NHS England could amend one or more provisions of the National Tariff during the period which it has effect, with appropriate safeguards We will also work closely with the NHS to reduce the health inequalities currently experienced in the area of choice, by helping to increase clarity and awareness of patient choice rights within systems and of the range of choices available. Reducing bureaucracy proposals Finally, our proposals will ensure a system that is more accountable and responsive to the people that work in it and the people that use it. Ministers have always been accountable, rightly, for NHS performance. Our proposals will ensure NHS England, in a new combined form, is accountable to government and the taxpayers that use it while maintaining its clinical and day-to-day operational independence. We will introduce measures to enhance quality and safety in the NHS, including the creation of an independent statutory body to oversee safety investigations. Alongside this we will work with local authorities to develop enhanced assurance frameworks for social care, that will support improved outcomes and experiences for people and their families. 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.

Over the last 2 years, we have seen NHS England and NHS Improvement come together to work effectively as a single organisation. We have seen clear benefits from them working in practice as one organisation providing national leadership: speaking with one voice, setting clearer and more consistent expectations for providers, commissioners and local health systems; removing unnecessary duplication; using collective resources more efficiently and effectively to support local health systems and ultimately making better use of public money.Building on the experience of the last few years, we now want to take forward proposals to legislate to clarify the central role of collaboration in driving performance and quality in the system, rather than competition. The proposals are to:

On current timeframes, and subject to Parliamentary business and successful passage, our plan is that these proposals for health and care reform will start to be implemented in 2022. We will continue to engage with stakeholders across the health and care systems, our arm’s length bodies and the devolved administrations on the detail of these proposals as they progress. We will also continue to work across government to ensure that the right systems and processes are in place that work for all, recognising the interdependencies between health and other social determinants. Annex A: Proposals for legislation Working together and supporting integration proposals Legislation of all kinds needs to be carefully calibrated to make only necessary and proportionate changes. The risk of legislative overreach and of an excessive specification of detail, spelling out the exact conditions under which specific organisations can and cannot work together, can lead to burdensome bureaucracy and confusion for those faced with the task of implementation. As the pandemic has shown, there is a great deal of insight, commitment and innovation in local organisations. We need a legislative framework that builds on the trust we have for those within systems to understand and deliver what their populations need.The public largely see the NHS as single organization and as local health systems work more closely together, the same needs to happen at a national level. The creation of statutory ICS NHS Bodies will also allow NHS England to have an explicit power to set a financial allocation or other financial objectives at a system level. There will be a duty placed on the ICS NHS Body to meet the system financial objectives which require financial balance to be delivered. NHS providers within the ICS will retain their current organisational financial statutory duties. The ICS NHS Body will not have the power to direct providers, and providers’ relationships with the Care Quality Commission will remain unchanged. However, these arrangements will be supplemented by a new duty to compel providers to have regard to the system financial objectives so both providers and ICS NHS Bodies are mutually invested in achieving financial control at system level. COVID-19 response. As of 9 February 2021, the UK has vaccinated 12.6 million people. In the early stages of the response, the NHS COVID-19 Data Store was established, which safely brought together accurate, real-time information necessary to inform decisions in response to the current pandemic in England

By bringing forward this proposal to formally bring NHS England and NHS Improvement together, we will remove these remaining bureaucratic and legislative barriers, enabling the organisation to legally come together as one to provide unified national leadership for the NHS. Unlike NHS Trusts, which are set annual capital expenditure limits by NHS Improvement, NHS Foundation Trusts ( FTs) currently have additional freedoms to borrow from commercial lenders and spend surpluses on capital projects (for example, new buildings, equipment or IT). However, capital expenditure by FTs still counts towards DHSC’s overall Capital Delegated Expenditure Limit (CDEL). In practice, we recognise that ICSs will have to develop effective and legitimate decision-making processes, and we are giving ICS NHS bodies and ICS Health and Care Partnership the flexibility to develop processes and structures which work most effectively for them. We also know that we need to support staff during organisational change by minimising uncertainty and limiting employment changes. We are therefore seeking to provide stability of employment and will work with NHSE and staff representatives to manage this process. In bringing forward these measures, we are determined to make the changes to legislation the NHS asked for and, given the government’s wider responsibilities for public health and social care, we intend to take forward a set of targeted legislative measures to support social care, public health and safety and quality. These proposals capture the initial learning from the experience of the health and care system in responding to the pandemic and make permanent some of the innovations where COVID-19 has accelerated new and better ways of working. They provide a framework which allows further evolution and will support, harness and sustain the collaboration and integration seen during COVID-19.NHS England response to the ICS consultation document and the government brings forward legislative proposals to support integration enable a greater range of delegation options for section 7A public health services, including the ability for onward delegation of the function into collaborative arrangements, such as a section 75 partnership arrangement As NHS Improvement currently consists of the NHS Trust Development Authority (NHS TDA) and Monitor, we are proposing to formally transfer their functions to NHS England and abolish Monitor and the NHS TDA. We are also planning to implement NHS England’s recommendation for a reserve power to set a capital spending limit on Foundation Trusts, which will support the third aim of the triple aim duty, in relation to sustainable use of NHS resources. The original set of national NHS bodies has already altered in form and purpose, and in the proposed legislation, we intend to continue the work already undertaken to formally bring together NHS England and NHS Improvement into a single legal organisation.