Integrated care systems aren’t provider-based organisations although providers are key partners, they are planning mechanisms to try and make sense of that complexity and fragmentation within the organisational landscape. But within them, at least within the larger and more complex ones, there are integrated care partnerships which are very much about how care is provided, so alliances of NHS providers working together, agreeing to collaborate rather than compete and including in their most advanced development hospitals, community services, mental health, GPs and social care and independent and third sector providers.
80% also will get delivered at a place-based partnership level in places like Sheffield and Doncaster and Barnsley and Wigan and Bolton and Trafford to give you those examples, with 20% perhaps being led at a system level. There is no manual. There is no guidebook that says this is what an integrated care system is, this is how it should be organised and this is what it should do. The colleagues involved in the ten integrated care systems are themselves writing the manual on system working.
You have the larger ICSs, Greater Manchester not far short of three million, South Yorkshire Bassetlaw 1.6 million. Large, complex, and the way I’ve been describing.
At the other extreme we’ve got Blackpool, about 300,00, you’ve got many of the ICSs around about the half, three quarter of a million size and there is a kind of emerging bubbling debate about, well can it be right that we have so much variation in size and complexity in the cohort in this first wave of ICSs and is there any move at all to begin to bring together the smaller ones to make them more like the bigger ones? I think there’s an obvious rationale for doing that but there are some big risks potentially as well, given the importance of the relationships within the systems and partnerships and the risk of putting those on one side for the sake of neatness around some kind of organisation map.
What are the emerging functions and roles of integrated care system? Well the way we’ve seen it, is there’s a planning function building on what the STPs have set up. It’s about how you then can align but not do the commissioning behind the plan. It’s about bringing together, over time, the functions of NHSE and I [NHS England and NHS Improvement] alongside the integrated care system. Putting it bluntly, the worst of all outcomes would be to add another layer of complexity called an integrated care system to the already too many layers of complexity we have in the fragmented complex legacy of the 2012 Act.
It’s about taking responsibility at a system level, for overseeing performance in the system. Self-evidently, it needs to be about the provision of system leadership on the issues that require system leadership and owning and resolving system challenges rather than looking externally for help from the management consultants or from the turnaround specialists or from others. This is all about collective leadership across the organisations and distributed leadership from the top to the bottom and the staffing of integrated care systems is developing through changes to the roles of CCGs, the roles of regulators and through secondments from partner organisations.
Greater Manchester has within it ten integrated care partnerships, to use my language. They call them local care organisations based around the boroughs and the City of Manchester, building the links between the hospital, for community services, GPs and local government, and they’re doing fantastic work in some parts of Greater Manchester. I’d highlight particularly the work I had the opportunity to visit with colleagues in Wigan to reach into their community and work with community organisations and the wider range of community assets in looking at the wider determinants and working across different sectors to address them.
So a lot of green shoots appearing but, be under no illusions, all of the ten areas face exactly the same operational pressures and stresses and strains, certainly through the winter as the rest of the NHS and why should we expect it to be any different when ICSs haven’t even celebrated their first birthday, with the exception of Greater Manchester.
So, I hope I’ve been moderately positive in my comments so far, but let’s recognise the reality, the harsh reality of the challenges in doing this work. Regulators have been, in my view, far too slow to align their work in the right way behind integrated care system and that continues to be a problem. I worry about the demands we’re placing on our leaders who have their organisational roles, their ICS roles, their partnership roles and so much more besides. Local authority involvement has been really positive in many places but not everywhere and we’ve got work to do to tackle that.
The concerns about is this really to do with privatisation and the two judicial review challenges have raised concerns in some quarters that have not been particularly helpful and integrated care systems have started to deliver, but we need to see more of that to reassure those that aren’t naturally supportive of the ICS system based working.