ICSs are intended to be a fundamental departure from previous NHS structures with a different type of leadership based on partnership, in which local partner organisations hold collective responsibility for resource use and outcomes. However, as ICSs take on statutory responsibilities for the first time later this year (assuming the Heath and Care Bill gains parliamentary approval) there is a risk of recreating established ways of working within the new structures. To live up to their promise, what are the things that should be ‘different’ about ICSs?
First, the concept of equal partnership between the NHS, local government, voluntary sector and others needs to be at the core of how these reforms are implemented. ICSs started their lives as informal partnerships operating through soft power and influence. The Health and Care Bill changes this by putting ICSs on a statutory footing, but partnership-working and collective responsibility need to remain at the heart of ICSs if they are to achieve their objectives. This has implications for both integrated care partnerships (ICPs) (the committees that will set system strategy) and integrated care boards (ICBs) (the new statutory bodies responsible for NHS budgets). The influence of local government, social care and voluntary sector organisations can’t be limited to discussions within ICPs – partners also need to have a material impact on decisions made by ICBs about resource use and prioritisation. A similar argument also applies to parts of the NHS whose voice is sometimes less well heard, such as primary care and mental health.
Second, the principle of subsidiarity to local places needs to be put into practice, as stressed by the guidance document Thriving places, the integration White Paper and The King’s Fund’s work on place-based partnerships. This will involve ICBs delegating some powers and budgets to place level, and just as importantly it will mean paying careful attention to the leadership behaviours and dynamics at the interface between the two levels. These reforms cannot be about creating a top-down hierarchy between system and place, but rather a two-way relationship in which place-based leaders and ICS leaders support and challenge each other to improve outcomes.
Third, upwards accountability to national bodies needs to be complemented by robust collective accountability, with local partners holding each other to account for delivery against shared priorities – and ultimately, stronger mechanisms for accountability to local people (including through the democratic mechanisms of local government). As part of the shared outcomes framework announced by the integration White Paper, there is an expectation that place-based partners will agree local priorities by April 2023. It is vital that these local priorities are not eclipsed by national imperatives, and that national and regional teams develop what contributors to a recent NHS Confederation report described as ‘adult-to-adult’ relationships with system and place leaders rather than management through top–down command and control.
Finally, ICSs need to become much more sophisticated at using insights from local people including patients, service users and families. ICSs cover large geographies so there are limits to how much granularity they can go into, but there needs to be channels through which locally gathered intelligence can flow from neighbourhood to place to system level. As we have argued in previous work, the best way to understand whether integration is delivering results is through the eyes of people using services.
Having spoken to a number of ICS leaders over recent months I don’t doubt that there is a genuine desire for ICSs to break new ground in the ways I’ve outlined, framed around an ethos of partnership and collective responsibility. However, my concern is whether people have the bandwidth to do the hard work of transforming ways of working and challenging established forms of leadership at a time when the system is under such pressure even to keep delivering the status quo.
In the short term, the immediate task of setting up the new arrangements is consuming much of this bandwidth, and the risk is that doing what is required (legally speaking) leaves little time for doing what is needed. Legislation is often a blunt tool, and while the Health and Care Bill includes various provisions intended to nudge organisations towards more collaborative behaviours (such as a new duty to co-operate across organisations), it is important to recognise that the notion of collective responsibility is not being enshrined into law directly – rather, it is something that health and care leaders will need to keep building over time, consciously and persistently.
If we lose sight of the underlying aims of these reforms there is a very real possibility that many ICBs will focus first and foremost on well-established NHS concerns, operating similarly to the clinical commissioning groups they replace but on a larger scale and with less connection to local communities and local government as a result. However, if health and care leaders succeed in holding onto the original vision for ICSs, the prize will be a system in which it is easier to work across organisational boundaries, to make effective use of the combined resources available in each local area, and to deliver improvements in health and wellbeing by doing so.