Ten areas of England are currently developing as ICSs and they were selected on the basis of the quality of their STPs and their ability to work at scale to improve health and care. It is expected that other areas will be added to the programme as they demonstrate the capabilities required to work in this way. So how much progress is being made?
The King’s Fund has been working alongside NHS and local government leaders in the 10 areas as they strengthen their leadership and develop the governance needed to operate as systems. Our work has given us invaluable insights into what is being done and the challenges encountered. The focus to date has been on building the capabilities needed for organisations to work together in this way and attention is now turning to how the 10 areas can deliver benefits for their populations.
Our assessment is that current and future ICSs must address the following development needs if they are to succeed in transforming health and care, building on new care models and related initiatives. In no particular order, these needs are:
- developing trust and relationships among and between leadership teams
- establishing governance arrangement to support system working
- committing to a shared vision and plans for implementing the vision
- identifying people with the right skills and experience to do the work
- communicating and engaging with partner organisations, staff and the public
- aligning commissioning behind the plans of the system
- working towards single regulatory oversight
- planning for a system control total and financial risk sharing.
The work involved in addressing these needs is time consuming and cannot be rushed. Leaders in STPs and integrated care systems have been heard to observe that ‘progress occurs at the speed of trust’, a view the Fund would endorse. This is much easier where there is a shared vision and a strong sense of common purpose between the organisations involved. Collaborative rather than heroic leadership holds the key to progress.
Areas like Greater Manchester that had a head start in working as systems are further ahead than others and this helps explain why progress in transforming health and care varies across England. Also important is continuity of senior leaders and a context in which NHS providers and commissioners have a track record of good performance. Conversely, areas where there has been a history of competitive behaviours or no previous experience of organisations working together are taking longer to realise the benefits.
The 10 areas vary widely in their size and complexity. Greater Manchester with a population of 2.7 million is at one extreme and its near neighbour, Blackpool and Fylde Coast, with a population of 300,000, is at the other. Larger systems contain within their boundaries a number of place-based integrated care partnerships operating on a similar scale to Blackpool and Fylde Coast. Smaller systems are likely to come together with other areas in due course to enable them to function at the scale needed to improve acute and specialist services across larger geographies.
It’s become clearer during the past year that many of the improvements in health and care set out in sustainability and transformation plans will be delivered in place-based integrated care partnerships involving local hospitals, community services, primary care, social care and other providers. These partnerships often provide the most promising possibilities to join up care around established communities for example, as in Salford and Barnsley. ICSs have a role in planning and supporting the development of integrated care partnerships, but the bulk of the work involved is best done in places themselves.
Within these partnerships, there is usually a strong focus on localities serving populations of around 50,000 where general practices collaborate with community teams and others to better meet the needs of the population they serve. Localities have become the key building blocks of integrated care both in STPs and ICSs. This is where patients and service users will experience the benefits, for example, in improved access to GPs and more services delivered in their own homes or closer to home.
Variations in the size and complexity of ICSs help explain different approaches to the role of commissioners. The role and configuration of clinical commissioning groups (CCGs) is changing everywhere with mergers in some cases, the establishment of executive teams across a number of CCGs in others, and closer working with local authorities in many places. The increasing involvement of local authorities in STPs and ICSs is bringing in new thinking and enabling the development of integrated commissioning.
Local authority participation is also moderating expectations of a rapid move to fewer, larger CCGs in some areas. This is particularly the case where co-terminosity between CCGs and councils is valued, as in the 10 places that make up the Greater Manchester system and the five places that exist within South Yorkshire and Bassetlaw. The challenge in these and other areas is how to align the work of CCGS behind system plans and create the capacity needed for strategic commissioning at scale.
The roles of NHS England and NHS Improvement are adapting in line with the development of ICSs. This is necessary to move regulation from a focus on organisations to systems and to avoid adding another layer of oversight into an already complex and fragmented set of organisational arrangements. Progress may not be as fast as the leaders of systems would wish, and old behaviours often trump new, but the direction of travel has been set and is likely to accelerate.
The way in which the challenges faced by Pennine Acute NHS Trust in Greater Manchester are being handled illustrates how regulation is changing. Support for Pennine Acute NHS Trust, which runs four acute hospitals, is overseen by the Greater Manchester Improvement Board, which is chaired by Jon Rouse, chief officer of the Greater Manchester Health and Social Care Partnership. It is being delivered by Salford Royal Foundation NHS Trust, under a management contract. Manchester University NHS Foundation Trust is working with Salford Royal to provide support to North Manchester General Hospital.
These bodies are working with commissioners and regulators and are lending their management and clinical expertise to address shortcomings identified in a Care Quality Commission inspection. Support includes medical specialists from Salford Royal and Manchester University trusts working in North Manchester to tackle the causes of some of its difficulties. The ownership of Pennine Acute’s challenges by Greater Manchester points to a future in which provider failure may be seen as a system, rather than organisational, responsibility.
Examples like this point to the promise of ICSs but the difficulties they face should not be underestimated. A recent example concerns plans for system control totals in 2018/19 and how these are reconciled with organisational control totals and the use of commissioner and provider sustainability funds. If control totals are not realistic, they could create significant financial disincentives to partnership working and bring into question the commitment of NHS organisations to continue working in this way.
Unlike many national initiatives, ICSs are evolving in a context which is permissive rather than prescriptive. Leaders in the 10 areas have therefore been able to adapt the broad framework in the Forward View update to their own circumstances and to contribute to the development of thinking at a national level. In so doing they have been writing the manual for system working rather than being readers expected to implement a blueprint written by others.
Really interested that the first bullet point refers to the need to develop trust and relationship between leadership teams - but then the bulk of the commentary returns to talk about structures and processes....I would be interested to hear more about the learning in relation to trust and relationships, and what can be done to support their development particularly given the observation that in the final report that old behaviours continue to trump new...
Overall the commentary is helpful and reflects what I see in the system -
As a Carer I feel completely marginalized. I have Legal Rights, and those we Care for also, however all I hear is about what 'integrated care systems' can offer to improve the system. I am part of the system. 'INNOVATION' is in short supply mainly because those 'pushing' for these changes really have no idea of the 'wider' picture' the 'puzzle' cannot be completed without the 'lived in experience' of those 'fighting' a system that can't possibly improve it, if they have not understood why it is going so badly wrong.
I am a Carer I want to be in control, a very long time ago I suggested 'electronic prescribing of prescription'? a GP said we won't have the time, now we have it. It is time GP/Integration? who already have the means to include electronic prescribing include us in this exercise. The Consultation is recorded on their COMPUTER add NAME of patient EMAIL Address and SEND, all subsequent test results will be attached and sent via email. The same applies to others included in our Care, then we will actually be in CONTROL and patient centred.
It is important to understand the 'vulnerable' physically' and those with learning disabilities, others with long term illness are RECORDED on their medical Records, those acting on their behalf will be included in my proposals.
My suggestion will provide 'patient centred' control, will act as a record of events, can be used in a Complaint situation.
I appreciate it will need 'fine tuning' but for myself I would find it excellent EXAMPLE GP consultation etc., prescribing, attachment of Test Results, would be in my hand, at present I PAY £5 to my surgery for these results? other Patients even those on Income Support are charged by some GPs for a Statement to apply for benefits. I would have been charged £32 for a GP letter for someone I am a DWP Appointee and they are on Income Support. It was necessary to remind them of this, the Receptionist questioned why it had been crossed out by the GP.
Patients on Income Support are entitled to Travel Costs when visiting Hospital 'OUTPATIENTS' including an ESCORT, but how many know this? This should be advertised more via a POSTER Campaign.
My 'highlighting' of what really matters to patients should be taken into account, you cannot possibly state 'integration care systems' will be successful with this latest IDEA, without understanding the reality of the Problems that face us all everyday.