Preparations for establishing 42 new Integrated Care Boards for the NHS in England are well underway. And since the Health and Care Act 2022 received Royal Assent at the end of April, there has been a steadily growing torrent of instructions and guidance to help systems be ready in time for the big changeover at the beginning of July. From guidance on drafting ICB constitutions to changes to digital systems and services, few aspects of local NHS governance remain untouched.

In among all that, NHSEI (NHS England and NHS Improvement) has released an update to its 2018 guidance on major service change: Planning assuring and delivering change for patients (PADS). Nothing unusual about that you might think. After all, we’re all expecting PADS to be updated to take account of the new legislation. This update, which takes the form of an addendum to the 2018 document, doesn’t deal in depth with the issues arising from the new legislation – it promises that for the future. In this update, NHSEI tackles the challenge of aligning the business case process for commissioning decisions with the process for applying for capital funds to implement changes

At the Institute, we like PADS. In 2018 we said the update was “an improvement on an already very helpful document.” And the addendum won’t change that. We’re pleased that it focuses on addressing one of the shortcomings we identified in our comments on the 2018 version: that the process requirements and sequencing of applying to NHS Improvement for capital funding where it’s needed to facilitate changes would need to be clarified.

Previously PADS told us there was the Capital regime, investment and property business case approval guidance for NHS trusts and foundation trusts (NHS Improvement 2016) and that document told us PADS sets out the process commissioners should follow when service reconfigurations are being considered. PADS told us that where capital was available “public and local authority consultation should be undertaken before a Strategic Outline Case for capital funding is submitted to NHS Improvement.”

So it seemed clear that the two processes butted up against each other. And with the Capital regime guidance requiring a six-case approach (the five HM Treasury ‘Green Book’ cases: strategic, economic, commercial, financial, and management cases; and the clinical quality case) it was clear that there were some advantages to be had in using the work completed for commissioning decisions to support the development of capital cases. That was reinforced when the Health Infrastructure Plan Guidance – HIP2 came out. In our briefing to HIP2 projects, we set it out as:

The practicalities of this had been learned in other recent new hospital programmes where systems had been allowed to progress straight from decision-making business case in the commissioning decision process to OBC (outline business case) in the capital application process.

Now the addendum to PADS seeks to maximise those potential efficiencies by aligning pre-consultation business cases and decision-making business cases with the five-case model.

It makes good sense. And we’re pleased that this picks up on the major shortcoming we identified in 2018: that there wasn’t enough detail on the development of change proposals that are to be presented in a public consultation.  But the new approach is not without its challenges.

Practically, change programmes will have to wrestle with the inherent conflicts between the legal expectations to explore and investigate possible solutions openly with the requirements of a process that forces them to a preferred way forward. At the moment, the addendum leaves that to programme leaders to reconcile and allows preferred “way(s)” forward at PCBC stage. That might be an ambitious rebranding of consultation options. It could risk a return to the dark days of public consultations on two options we don’t want and one we do.

Elsewhere in the document, Annex 1 sets out the content requirements for a PCBC and a SOC in a table. Institute members have said they’ve struggled to read the table at first, and we agree it’s isn’t the easiest table to read, but it’s worth the effort to get your head round. You’ll see it sets out the overlap between the two documents and the efficiencies you can reap in the process.

Annex 2 updates the list of best-practice checks programmes have to undertake before submitting a PCBC. There are helpful additions around finance that echo the main thrust of the update. There are additions that recognise the shift from STPs to ICSs, a need to provide evidence of alignment with system plans and the NHS Long Term Plan, and local population health priorities. And a very helpful specific check to evidence that duties to reduce health inequalities have been considered and attended to.

All in all, the addendum offers a largely positive step forward. The issue of how these two important processes link together in practice was largely left open by current guidance. This update grabs that issue with two hands and attempts to force it into submission. For that ambition alone it we applaud it.