What does the future hold for integrated care systems?

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NHS England’s belated decision to change the name of accountable care systems to integrated care systems has the virtue of describing more accurately the work being done in the 10 areas of England operating in this way. Despite this, there is understandable confusion in many quarters about NHS England’s plans, and uncertainty about what they mean for the NHS in the medium term.
 

Integrated care systems, as they were re-branded in updated planning guidance published recently by NHS England, bring together NHS commissioners, providers and local authorities to plan how to improve health and care for the populations they serve. For the organisations involved in these systems, lines of accountability remain unchanged. NHS organisations continue to look upwards to NHS England and NHS Improvement and local authorities look outwards to their communities. Many systems are also working to establish a form of mutual accountability in which the organisations involved hold each other to account for the delivery of their plans.

Mutual accountability hinges on the existence of a high degree of trust and respect between organisations and their leaders. It also requires the establishment of governance arrangements that support collaboration while respecting the statutory responsibilities of these organisations. Integrated care systems have no basis in law and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so. 

These systems also require NHS England and NHS Improvement to work together to oversee how areas working in this way are performing. This is beginning to happen in some areas through joint working by teams drawn from national bodies and the development of single regulatory oversight. NHS England’s expectation is that integrated care systems will become self-governing as they mature and that regulatory intervention will then be the exception rather than the rule, but this is some way off in most areas. 

The updated planning guidance makes clear that integrated systems will become increasingly important in planning services and managing resources in future.

The updated planning guidance makes clear that integrated systems will become increasingly important in planning services and managing resources in future. The 10 areas already operating in this way will prepare a single system operating plan and take responsibility for a system control in 2018/19. The guidance also states that other systems will join the programme where they can demonstrate strong leadership, a track record of delivery, strong financial management, a coherent and defined population, and compelling plans to integrate care. The message could not be clearer: system working is here to stay.

Integrated care systems, like the sustainability and transformation partnerships from which they have evolved, are conscious workarounds which seek to make sense of the complex and fragmented organisational arrangements resulting from the Health and Social Care Act 2012. Changes to the law to regularise what is happening, included in the Conservative Party’s 2017 election manifesto, are off the agenda for the time being. This is because the government lacks a working majority and also because Brexit is dominating the parliamentary timetable. 

The difficulty this creates is that workarounds are inherently unstable, even in the most favourable circumstances, and can only be sustained for so long. Informal mechanisms such as memoranda of understanding and partnership boards to underpin decisions about the use of NHS resources have a part to play but may break down when difficult decisions arise. There are worries too that decisions will be taken behind closed doors in forums that have no statutory basis and are not open to public scrutiny. 

There are worries that decisions will be taken behind closed doors in forums that have no statutory basis and are not open to public scrutiny.

Changing the name of accountable care systems to integrated care systems will not distract attention from concerns by campaigners about a proposed national contract for accountable care organisations which they fear will result in ‘backdoor privatisation’. The contract is intended to be used by NHS commissioners who wish to undertake a competitive procurement process to integrate the delivery of care for their populations. NHS England has responded to the concerns raised by delaying the contract’s introduction and agreeing to consult on how it expects it to be used.

The puzzle is why the proposed contract is needed when many areas of England have already made moves to integrate care making use of existing legislative flexibilities. These areas are working with NHS providers to align hospital, community and mental health services, with GPs and adult social care services also involved in some places. They are doing so in a variety of ways, including through the use of alliance contracts and lead providers who subcontract with other providers to join up care in public sector partnerships.. 

Where this is happening, the emphasis on collaboration between commissioners and providers appears to run counter to the intention that the proposed contract should be used in a competitive procurement process. Clinical commissioning groups are also often uncertain on when they are required to go out to tender for the services they commission and are alert to the possibility of legal challenges from private companies who may feel excluded from decisions to keep contracts within the NHS family. The NHS market may be dying but is not yet dead, underlining the tension at the heart of recent developments.

For the foreseeable future, the NHS and its partners will have to live with this tension and the ambiguity it creates. They will also hope that the political will can be found before too long to align the law with the priority now being given to integrated care and partnership working. Is it too much to expect a cross party consensus to emerge that will make this possible?

Comments

John Kapp

Position
director,
Organisation
SECTCo
Comment date
08 February 2018

What happened to the Any Willing Provider in the white paper 'Liberating the NHS' in 2010? Trump was right to say on 6.2.18 that the NHS is broke and doesn't work. This is because the only treatments that GPs can prescribe are drugs whose harmful side effects are worse than the disease, causing patients to keep coming back in a revolving door. GPs are forced to break their oath 'do no harm', so feel so guilty and ashamed they take early retirement at 55. The solution is HWBs to instruct CCGs to mass-commission psycho-education courses teaching self care in Community Care Centres, as mental A&Es.

Mr R W Ebley

Position
Retired,
Comment date
09 February 2018

In order that change is effectively undertaken all levels of government and other public funded organisations need to demonstrate good management

Independent management accreditation is required to achieve this

Thank you

David Peach

Position
Retired,
Organisation
NHS user
Comment date
13 February 2018

So you want to stop GPs for prescribing drugs, so you want the patients to attend self care in the community centres. i.e. Mental A&Es So this will cure serious health issues without drugs. So will there be an influx of Witch Doctors into our New NHS system The NHS isn't working and broke because of JAMES HUNTS interference removing hospital beds closing wards and causing suffering and premature deaths in ambulances, corridors through waiting times lasting hours. and wards due to infections from dubious private cleaning contractors

Jeremy Labram

Position
Management Consultant,
Organisation
Mr
Comment date
15 March 2018

I entered this world of joint working between councils and the NHS 6 years ago and worked on Care Act (2104) implementation, Better Care Funds (BCF), Section 75 agreements (to allow financial risk to be shared between the two parties), the start of Sustainable Transformation Partnerships (STP) and their interest in adopting the Accountable Care Partnership (ACP) model. Now we're onto Integrated Care Partnerships (ICPs, no doubt). There are plenty of other parallel initiatives running in each of the two main silos (health and social care) which have to ignore the integration stuff just to keep going at all. This is probably enough to demonstrate that we are wandering around trying to find the ultimate fix by trial and continual error to a disjointed system of many moving parts.

The challenge is made all the more challenging as it is being carried out by 211 Clinical Commissioning Groups (CCG) and 150 local authorities (LA), who are by no means all 'co-terminate' – i.e. their catchment areas are not the same - so next door neighbours can belong to different GP practices belonging to different CCGs, which themselves have relationships with different LAs.

This is really messy. My first piece of advice as a budding management consultant in the private sector was ‘never to outsource a mess’. Along with that was, if the supply arrangement, was business critical, ‘always have a back-up’. In other words always split the business between competing suppliers.

What I discovered utterly confounded me: the CCGs were making deals with monopolies and LAs were outsourcing social care messes.

If there was any competition at all it was the NHS and the LA arguing over who should pay for an individual’s care. If social care services survived being outsourced they would always cost more than was originally tendered and perform really badly as soon as the enormity of the mess was discovered by the providers.

With all this well-meaning activity going on in a multiplicity of places in the England someone somewhere must be making a success of it, he says hopefully, and make this an exemplar. If not, then we must carry on with the quoted ‘work-rounds’ until someone brave looks abroad for success stories there – Holland, Valencia?

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