The System: A Guide
The mental health system, and the systems working alongside and within it, can be confusing to navigate and even harder to work out who is responsible or accountable for what, and why. First Do No Harm has put together an intermediary guide to what-means-what, how to get appropriate support from the right places, and where accountability lies.
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Accountability: who is responsible and accountable for what?
ICSs, ICBs, ICPs and Provider Collaboratives- what are they, and how do they work?
Integrated Care Systems (ICSs)
Integrated Care Boards (ICBs)
Integrated Care Partnerships (ICPs)
ICSs have been around since 2016 as an informal and voluntary way of different organisations working together to provide care. Since 2022, when the new Health and Care Act was introduced, ICSs received statutory powers and responsibilities to improve outcomes and access to health care, alongside financially restructuring funding and expenditure of care services. Within ICSs, there sit 2 key bodies:
ICBs allocate NHS budgets and are responsible for the commissioning of specialist services (including inpatient hospitals owned and operated by private care providers). Sections 3 and 3A of the National Health Service Act 2006 outline the responsibilities of ICBs in the commissioning of certain health services. ICBs are directly accountable to NHS England for expenditure and performance of the local ICB, irrespective of whether the ICB delegates their responsibilities to specific committees sat within the ICB.
ICBs operate as ‘unitary boards’, meaning that multiple people sit on a committee including a chair, chief executive officer and at least three other members from NHS trusts and foundation trusts, general practice (GPs) and the local authority. An additional member must have knowledge and expertise of mental health services in the area, and ICBs are prevented from appointing individuals from private sector organisations.
What about CAMHS, CMHTs and other mental health services in my area? ICBs oversee and delegate funding to all mental health services at ‘ground level’. This means that, whilst there’s no doubt someone responsible within your local CAMHS team, there is also an NHS trust who acts as a Lead Provider for mental health provision that sits at a higher level as part of the ICB.
ICPs are statutory joint committees with local authorities, members of ICBs, Healthwatch and VCSE (Voluntary Community Social Enterprise) organisations. ICPs are responsible for maintaining strategic partnership with various partners to meet the wider and long-term health, public health and social care needs of the population. They do not commission services.
You can read more about ICSs here.
Provider Collaboratives, like ICSs, have now been formalised as partnerships to improve the efficiency and quality of care and services across a geographical area. While Provider Collaboratives are not legislative bodies in themselves, it is mandatory for all NHS trusts providing mental health services in an area to join a Collaborative. For independent or private providers, however, it is not compulsory and instead encouraged and decided by whether there is benefit for the local population for such providers to be included in the Provider Collaborative.
Usually there is a Lead Provider in the Collaborative that takes responsibility for contracting and providing a set of services in an area and all providers contribute to a shared delivery of the services. This means that there is one Lead Provider responsible for the delivery of mental health services in an area; ICBs and NHS England commission specialist mental health services (including private services, like Huntercombe/ACG or the Priory Group) that are under the responsibility of said Lead Provider.
You can read more about Provider Collaboratives here.
The confusing bit is that a private mental health hospital doesn’t necessarily sit within an ICB’s or Provider Collaborative's area simply because it’s located there; Provider Collaboratives and ICBs don’t have the same name or geographical area either. To put it another way, ICBs cover large geographical footprints, and Provider Collaboratives typically cover smaller areas.
To use Taplow Manor (Huntercombe Maidenhead) as an example:
The hospital is geographically located in Maidenhead, Berkshire. The ICB responsible for commissioning and contracting Taplow Manor (amongst other independent providers) is Buckinghamshire, Oxford and Berkshire West ICB, which consists of 6 NHS Trusts, 5 Local Authorities and District Councils and 1 Academic Health and Science Network. Steve McManus is the board’s Interim Chief Executive Officer. The Trust responsible for child and adult mental health services within the ICB is Oxford Health NHS Foundation Trust. The current Chief Executive Officer of the trust is Dr Nick Broughton, and the trust is the Lead Provider for Thames Valley CAMHS Tier 4 Provider Collaborative and, as we’ve already seen, independent providers can join these Collaboratives; Huntercombe/ACG are part of this Provider Collaborative.
For Ivetsey Bank:
The hospital is located in Wheaton Aston, Staffordshire. The ICB responsible for the commissioning and contracting of Ivetsey Bank is Staffordshire and Stoke-on-Trent ICB. Peter Axon is the ICBs current Interim Chief Executive Officer. Within this ICB, the NHS trust responsible for inpatient child and adult mental health services is North Staffordshire Combined Healthcare NHS Trust, and the current Chief Executive of the trust is Dr Buki Adeyemo. The trust is part of the West Midlands CYPMHS Provider Collaborative (WMCPC), but the Lead Provider of the collaborative is Birmingham Women’s and Children’s NHS Foundation Trust.
As of April 2023, NHS England has delegated commissioning responsibilities to ICBs, including specialised mental health services such as CAMHS Tier 4 hospitals, and eating disorder units.
This means that, from April 2023, NHS England and NHS Improvement will “discharge its accountability for commissioning specialised services in respect of both those services that are delegated to ICBs and those that are retained.” Instead, new governance models have been developed; for specialist mental health services, the Delegated Commissioning Group for Specialist Services (DCG) has been established. Note that the DCG is not responsible for the explicit commissioning of specialist services, but “will manage the approval of national standards, approve gateways for national transformation programmes, guide support to regions and ICBs, and provide oversight (as appropriate to the assurance frameworks) of these services.”
This will be a slow and complicated process though, and likely to be subject to more changes in future. More detailed information is provided in NHS England’s Roadmap for integrating specialised services within Integrated Care Systems.
But my ICB isn’t the same one that the hospital is under, so who’s accountable?
The short answer? Both.
We know that most admissions to CAMHS inpatient hospitals are nearly always ‘out-of-area placements’ because, frankly, specialist services are few and far between and aren’t something you find on your doorstep. According to the most recent NHS ‘Who Pays?’ guidance, the ICB known as the ‘originating ICB’ is responsible for the commissioning (referral, responsibility and oversight) and payment of a child’s placement in a service provision and overall care needs when the child is:
a looked after child with the local authority
detained under the Mental Health Act (MHA).
eligible for section 117 aftercare after being sectioned under the MHA.
issued an Education Health and Care Plan that has identified the specific care need.
requiring accommodation in a care home, children’s home, residential school, foster care or an independent hospital.
Irrespective of whether ICBs and/or local authorities have arranged the accommodation/admittance of a child into a service provision that sits in another ICBs geographical area, the ‘originating ICB’ remains responsible for the costs and commissioning of said service. There are some (or a lot of) exceptions but, with the demographic of people receiving mental health care, the above is usually the case. In short, this means that ‘your’ ICB is ultimately responsible for having paid for and, in most cases, arranged for you or your child’s care, including a hospital that falls under a different ICB.
Having said all this, the question of who’s accountable also refers to the quality, or lack, of the care provided for you or your child. Ultimately, Integrated Care Systems (and each statutory body within it) have been set up with a fundamental purpose to improve access to timely, appropriate, safe and effective care. If an ICS in an area is utilising a private hospital where care is not being provided and people are being mistreated, accountability lies with those statutory bodies that make up the ICS for failing to provide appropriate oversight, monitoring and governance on the quality and provision of care and treatment in that area. So, the ICB, ICP, and Provider Collaborative where the hospital itself is geographically located are also accountable. In other words, each statutory body that makes up an ICS is responsible, and therefore accountable, for the systemic failings in both quality, funding and provision of care in that area.
Why do ICSs keep using places like Huntercombe/ACG if so many people have had such awful experiences with them?
The simple answer is that, while ICSs are intended to remove gaps in quality, fragmentation and access to care within a geographical area, a single ICS doesn’t usually talk with another ICS. This means that, so often, ICBs in one area aren’t actually aware of a hospital’s failings that another ICB has identified in a different area.
The System from a high level perspective; the Department for Health and Social Care, its' arms-length bodies, and their role.
The Department for Health and Social Care (DHSC)
Public Health England has now been disbanded following two concurrent shake ups of the Public Health System in 2021. Public Health England’s responsibilities have been split into two separate organisations: the UK Health Security Agency has taken on health protection functions, and the Office for Health Improvement and Disparities now has responsibility for health promotion and improvement, as well as addressing health inequalities; this office is now the new directorate of the Department for Health and Social Care (DHSC).
The DHSC is responsible for policy, legislation, funding and delivery of health and care in England. It has oversight over a number of non-departmental public bodies and executive agencies, known as arm's-length bodies. Between the DHSC and its arm's-length bodies, there are framework agreements in place to decide how the two will work together and how the DHSC holds each arm's-length body to account. The DHSC is directly accountable to parliament.
NHS England (NHSE) is the largest arm’s-length body under the DHSC. The department provides a budget of just under £148 billion and its operational objectives are set by the DHSC annually in the NHS Mandate.
NHSE is led by a board consisting of executive and non-executive members (executive members have management responsibilities, non-executive members don’t) who, amongst other things, are responsible for holding NHSE to account in terms of performance and overall running of the organisation.
The Health and Care Act 2022 made changes at local system level with the introduction of ICSs, ICBs and ICPs and also rejigged national accountability; NHS Digital, NHSX and Health Education England are also now all part of NHS England and thus accountable via the NHS Chief Executive to NHSE’s board.
NHSE allocates funds to ICBs and allows ICBs to arrange and commission services that meet the needs of their local population. Some services remain commissioned by NHSE itself, but mental health services are commissioned by ICBs as of April 2023. In consultation with the DHSC, NHSE produces operational guidance for ICBs; operational and financial performance of all ICBs is monitored by NHSE regional offices. According to the NHS’ Roadmap for integrating specialised services within Integrated Care Systems, “NHS England and NHS Improvement retains accountability for the entire portfolio of specialised services – regardless of whether a service is retained by NHS England and NHS Improvement or falls within scope of delegated commissioning arrangements. NHS England and NHS Improvement will need to discharge its accountability through appropriate assurance and oversight arrangements [...]".
This means that ICSs, ICBs, and the services they choose to commission (like Huntercombe/ACG) are accountable to NHSE. In turn, NHSE is accountable to both parliament and the DHSC.
And the Care Quality Commission (CQC)?
The CQC is responsible for the registration of health and care providers, as well as the monitoring, inspection and regulation of health and adult social care services. They also have a regulatory role in monitoring the use of the Mental Health Act 1983 and Liberty Protection Safeguards. Changes in the Health and Care Act 2022 mean that the CQC now has statutory (enshrined in law) functions to assess and review the performance of ICSs and local authority commissioning of adult social care. The CQC do not create the regulatory standards that they measure themselves; instead, these are set out in legislation. However, the CQC has complete independence over how it regulates, inspects and rates services; the DHSC cannot intervene on specific cases or inspections.
The CQC is also an arm’s length body, led by a board of non-executive and executive members. CQC are funded in part by the DHSC, and in part by registration fees paid by the providers that CQC itself regulates. The CQC is directly accountable to parliament and the DHSC; their tri-annual strategic plan is developed in conjunction with the Secretary of State for Health and Social Care.
Healthwatch England is an independent committee. Its chair sits on the CQC’s board as a non-executive member. The CQC has oversight of Healthwatch England, and the organisation must consult the CQC on business plan developments and strategic priorities, however Healthwatch England has financial independence from the CQC.
Local Healthwatch organisations (for which Healthwatch England provides leadership, advice and guidance) are funded by and accountable to local authorities. These local organisations gather information, concerns and views about care services in an area.
Healthwatch England has a legal responsibility to escalate concerns raised by their local organisations to the CQC; they also advise the Secretary of State for Health and Social Care, NHS England and local authorities on where there are significant inadequacies in local services. The Chief Executive of the CQC is accountable for Healthwatch England’s expenditure of public funds.
Healthcare Services Safety Investigation Branch (HSSIB)
HSSIB is a statutory arm's-length body established by the Health and Care Act 2022. As of April 2023, HSSIB investigates reported incidents of poor care in relation to patient safety and is able to investigate both NHS and independent/private providers, as well as entering and inspecting specific services as part of investigations.
The investigations they carry out will place emphasis on what lessons can be learnt from the concerns, and HSSIB cannot regulate or place blame like the CQC. Anyone is able to report a concern to HSSIB, but an investigation will only be undertaken if the concerns meet certain criteria. HSSIB is directly accountable to the DHSC.
You can read more about the health and care system’s accountability structure here.
Simple, yet convoluted?
So, we can see that the health and care system’s accountability structure in England is, in theory, quite simple; yet it’s complex enough that no one seems to be held to account when things go wrong.
Ultimately, the DHSC is accountable in both its funding of, and mandate for, activities and care commissioned and performed by NHS England. Yet, when holding the DHSC accountable for specific failings of a private care provider, we can see that the DHSC’s oversight and accountability becomes overstretched, or overwhelmed, by the sheer amount of specialist care that NHSE outsources, contracts and commissions.
Whether useful or not, the accountability flow ultimately holds each body, organisation and provider accountable at every level; the private provider themselves, the Lead Provider of the local ICB and Provider Collaborative, NHSE for continuing to sign off on private provider contracts, and the DHSC setting out budgets and mandates. We know that the CQC is responsible for the registration and regulation of such services, who are ultimately accountable to DHSC.
When someone suffers at the hands of a private care provider, or any hospital and care setting in general, we are told to take it to the ‘right’ people, to make a complaint and escalate that complaint once the initial recipient decides that it’s out of their remit. People often find themselves in a cyclical battle, chasing their tails, getting more questions and the same-old ‘this isn’t our fault’ or ‘you’ll need to take this to someone else’ rhetoric. At every level, there is accountability for continuing to allow repeated and sustained systemic failings, abuse and neglect in both private and NHS hospitals. The question is, then, how do we move each concern up the chain of accountability? How do we ensure our concerns are specific to what each body, partnership or organisation are accountable for? How can these organisations hold themselves to account? How do we stand and say, ‘no, this is your area, and you are accountable’?