For those of us who believe that greater service integration within and beyond the health service is essential to improving care and achieving financial sustainability, recent events may have offered some encouragement. In his welcome apology at the NHS Providers' conference for the mishandling of the NHSE and ICB restructuring process, the secretary of state Wes Streeting also reasserted the importance of ICBs in the ambitions of the Government's 10-Year Plan. 

Then there is the advanced foundation trust (AFT) programme – guide for applicants published this month. Among other things, this seeks to square the circle of two aspects of the 10-Year Plan: more encouragement of provider autonomy and ambition, on the one hand; and greater collaboration to drive the left shift and more preventative model of care, on the other. The first key assessment criterion for AFT applicants is stated as: is the trust well-led, collaborating with system partners to improve population health and tackle inequalities, and responsive to local communities? 

AFTs are a step on the potential road to the unhelpfully named IHOs (it would have been so much better had we talked from the start about Integrated Health Contracts). This criterion alongside the secretary of state emphasising IHOs can be from any sector, including primary, and the fact that none of the eight initial chosen candidates are purely acute providers, does help address the fear in some quarters that these new organisations were a route to takeover by large acutes.

Then there is the strategic commissioning framework published earlier this month. To quote from the NHS Confederation's summary: ‘In our annual report on the state of ICSs, ICB leaders told us they feel optimistic about the potential for strategic commissioning to improve the health of patients and residents. 

‘The framework offers a direction of travel that chimes with what many NHS leaders told us earlier this year, that strategic commissioning is about collaborating with local government and wider system partners, looking over longer-term time horizons, prioritising transformation and left shift, and engaging meaningfully with patients and communities to drive the shift to new integrated models of neighbourhood care.' 

While the AFT framework encourages a stronger focus on collaboration, other accountability processes, notably league tables, not only centre on organisational performance but, particularly in relation to finances, seem to discourage mutual aid between trusts.  

AFT's are promised freedoms but these are largely based on slightly amorphous promises of less national oversight along with the ability to invest their very hypothetical surpluses (which also implies that all other trusts will be stuck with the current unwieldy capital approval processes). 

As for ICBs, despite their skills and ambition, it will be a massive stretch to do all the good things in the commissioning framework while also fulfilling the statutory responsibilities that will stay with them until a new NHS Act is passed, particularly in the context of 50% cuts to their running costs and with restructure processes now progressing at pace. 

Systems will be pleased to see the emphasis on population health, working with local government, engaging users and even the lesser spotted 4th purpose. But this sounds a lot like the ambitions with which ICSs were established, and now, as then (see the Hewitt review), it is hard not to question the willingness of the centre to support this expansive account of their role.  

The counter argument may be to point out that ICBs will no longer have performance oversight responsibilities, but as the framework makes clear, in setting contracts ICBs will have to assure themselves of provider quality and efficiency and willingness to collaborate, not just overall but in relation to specific services and pathways. 

However, the most fundamental problem hovers over both these documents and the many more we are promised.  Put simply: nationally the NHS is too centralised, locally it is too divided. The irony is that just about every round of reforms over the last five decades can be seen as offering ways to address these flaws. 

Instead, recovery relies on confronting the deeper-seated reasons for a pathology and being willing to undertake the work of confronting and overcoming those reasons. That continues to be a bridge too far.  

It is this inability to confront the structural causes of policy failure which help to explain the many contradictions of the 10-Year Plan, why the centre is reconstructing ICBs when they could simply have been reformed, why leaders don't know whether to focus on organisational accountability or collaboration, why each new set of guidance seems to contradict other bits of policy, and why a talented and committed secretary of state who promised not to reorganise the NHS is now presiding over a blizzard of reforms while also preparing for the exhausting and risky process of passing a new NHS Act.