Are ICSs getting off to the right start?

1. Are ICSs focusing on system-wide solutions for system-wide problems?

Many of the greatest issues in health and care today – staffing shortages, long waiting lists, deepening health inequalities – require solutions that span many parts of the system. For example, to play their part in addressing the workforce crisis in health and care, we would hope to see ICSs and their partner organisations pulling all the levers they collectively have available. This could include making it easier for staff to move across organisational boundaries, growing attractive and flexible career opportunities and making the best use of broader support available through the contributions of voluntary, community and social enterprise organisations (VCSE), and volunteers and communities themselves. Similarly, to manage demand for services in both the short and longer term, ICSs will need to avoid a narrow emphasis on acute sector waiting lists and focus on the support they can offer to primary, community and mental health services, the availability and quality of social care provision in their areas, and efforts to tackle health inequalities. This is exactly the type of system-wide approach that ICSs were created to support.

2. Is the NHS really shaking off its dependence on top–down performance management?

In the grand scheme of NHS reforms the 2022 Health and Care Act is relatively permissive, leaving local leaders a good deal of discretion to develop arrangements to suit local contexts. But this is an approach that is countercultural for much of the NHS, and old habits die hard. We are already hearing from some ICSs that parts of the national and regional NHS are taking overly prescriptive approaches to overseeing the form and functions of ICSs, passing down excessive and unrealistic asks. Conversely, there have also been calls in some quarters for more guidance on how ICSs should operate. It remains to be seen whether national NHS bodies can model new ways of working in their dealings with ICSs, and whether ICSs can do likewise in their relationships with their local places and stakeholders. Finding the balance between top–down and bottom–up approaches is not easy, but getting this right will be key to preserving the strengths of the more permissive approach set out in the Act.

3. Do ICSs feel like equal partnerships between the NHS, local government, voluntary sector organisations and others?

ICSs started their lives as informal partnerships bringing together organisations across local areas. While formal powers and responsibilities should make it easier for them to operate, they could also make it harder to hold onto the sense of partnership and local ownership that has been central to their work to date. In particular, integrated care boards (ICBs) have now been established as NHS organisations with significant budgets, responsibilities and staff. But partnership working will need to remain at the heart of how ICSs work if they are to achieve their objectives.

As Chris Naylor discussed in a recent blog, this has implications for both integrated care partnerships (ICPs) (the committees with cross-system membership that will set the overall strategy for each ICS) and ICBs (the new statutory bodies responsible for NHS budgets). The influence of local government, VCSE organisations and communities (as well as parts of the NHS such as primary care and mental health whose voices are often less well heard) can’t be limited to discussions within ICPs, but should routinely shape decisions made by ICBs about priorities and resource use. This doesn’t mean growing the boards of ICBs to cover all corners of the system; the boards themselves need to be a workable size to make decisions and be meaningfully accountable for those decisions. But ICBs will need to think carefully about how they relate to their ICP, how priorities are set and how the ICS executes its functions.

4. Are ICSs focused on the real work of integrating services, improving population health and reducing inequalities?

Those involved in setting up ICBs and ICPs have, understandably, been focusing on structures and governance while they establish new bodies and prepare them to take on new legal responsibilities. Going forward, we would hope their core focus to return to the work they need to do together with their partners to integrate care, improve population health and reduce inequalities, working collectively on specific priority areas (amending their ways of working and governance to support this as required). ICSs will need to become much more sophisticated at using data and insights from local communities to understand if this work is making a difference.

This also underlines the continued importance of starting from local places and neighbourhoods as the building blocks of ICSs as, (while being able to operate at scale will undoubtedly give ICSs more power to tackle some of the major strategic issues in health and care) much of the work of joining up services and improving population health needs to happen more locally. As we have outlined elsewhere, this will require ICBs to delegate some responsibilities and budgets to place level, and to pay attention to the dynamics emerging between system and place. Signs of this working would be if plans and decisions made by ICSs are being shaped by place-level priorities and insights, with strong connections developing between priorities, governance and leaders at the different levels.

5. Are providers and commissioners working together with a shared focus on outcomes?

The NHS has been pursing competition as a goal since 1989, with the commissioner-provider split at its heart. Changing behaviours towards a more collaborative model is at the heart of the reforms but changing behaviours and culture is not easy. ICBs have subsumed the previous roles and functions of clinical commissioning groups and taken on many of their staff and leadership teams, while provider leadership remains largely unchanged. There is a risk that ICBs take up their role by acting as large commissioning bodies, facing up against the also large (and probably sometimes more powerful) networks of providers that are forming through provider collaboratives. But this would miss the shift from transactional to collaborative relationships. Instead, commissioners and providers need to work hand in hand to plan and improve care for their populations. This requires a collective focus on outcomes, with providers thinking in a different way about the resources available and ICBs avoiding a transactional or contractual focus. Again, this underlines the need to nurture different ways of working that challenge the status quo.

The risks and challenges we have outlined here do not mean that the move to formalise ICSs has failed before it has begun. It has always been clear that it is not possible to legislate for collaboration between local services but that this requires changes to behaviours, attitudes and relationships among staff and leaders right across the system. It won’t be easy to find the bandwidth to do the hard work of changing ways of working when the sector is under such pressure. But if ICSs can keep sight of their core ambitions and the ethos of system working, then there is an opportunity to find new and better ways of responding to those challenges.