A year of integrated care systems: Bedfordshire, Luton and Milton Keynes

The Bedfordshire, Luton and Milton Keynes (BLMK) integrated care system (ICS) covers the three geographical areas and, following discussions over many years, was created specifically for the sustainability and transformation plan (STP). It covers a population of 985,000, which is expected to increase by more than 160,000 (17 per cent) over the next 15 years – double the national average rate of projected growth.

BLMK is an area with mixed levels of deprivation as well as significant ethnic diversity in the urban centres of Luton and Milton Keynes when compared to the more rural Central Bedfordshire.

The ICS has multiple relationships and a total of 15 organisations involved in the work, with four local councils and three clinical commissioning groups (CCGs). The boundaries of Luton and Milton Keynes CCGs are co-terminous with their council counterparts, while Bedfordshire CCG incorporates and works across Bedford Borough Council and Central Bedfordshire Council. There are three acute trusts, four community and mental health trusts and two ambulance trusts. In addition, Central Bedfordshire residents use services at a number of acute trusts outside the ICS. In terms of the three acute hospitals, Milton Keynes looks towards Oxford for its tertiary services, Bedfordshire looks to Cambridge and Luton to London. All the community, mental health and ambulance services supporting BLMK residents cover other ICSs. This adds further complexity and means that the sense of place around individual council boundaries is strong, and, for some, is as or more important than the ICS as a whole. 

ICS structure and governance

BLMK has described its system as a three-tier model. Tier 1 is the level of locality based on a population of around 30,000 to 50,000, organised around primary care, community, mental health services and social care, and is focused on resilient, multi-professional extended primary care networks, which support residents in proactive care management locally, across place and the system. Tier 2 is the level of place, organised around the four councils with populations of around 250,000 in care collaboratives focused on outcome-based commissioning and place-sensitised integrated delivery. Tier 3 is the level of scale for the whole ICS of around 1 million people and is concentrating on pooled commissioning, capitation risk management, systems integration and system-level investment.

BLMK’s governance has developed incrementally, with each organisation contributing time and resources to the ICS. The key forum is the 15-strong chief executive officer (CEO) group, in which all organisations and general practice are represented. This group sets strategic direction, which in year two culminated in a single operating plan across all commissioners and providers. It is the main decision-making body and is responsible for shaping and driving the ICS’s work. Decisions are taken on a consensus basis and the group is supported by a programme management office. A chief of staff exists in the role of managing director for the ICS with a small team of supporting colleagues. The transformation director/programme director supports a small team of system colleagues, either fully or in part seconded to the team from its constituent organisations. There have also been additional NHS five year forward view-dedicated programme leads funded by NHS England regionally. These local leaders have been critical in facilitating collaboration through building on local historic relationships, identifying and working with innovators and champions, and supporting chief executives in changing behaviours. Work is now under way to create a stronger executive function to help pace and scale of delivery. Recruitment for a full-time financial officer, chief information officer and re-engineering lead is nearing completion.

When the STP was created, the senior responsible officer was an experienced acute provider chief executive but following their move to a national role, a local authority chief executive took over the role. 

ICS priorities

The STP established five priority areas, which continue to be the focus of work for the ICS.

• Prevention including work on wellbeing, cardiovascular disease, seasonal flu, smoke-free estates and social prescribing.

• Out-of-hospital care including care home capacity, workforce and enhanced care homes initiative, investing in primary care networks, transformation of the palliative care pathway, and transforming the management of respiratory conditions in 0–4 year-olds.

• Sustainable secondary care including the proposed merger of Bedfordshire hospitals, back-office functions/shared services.

• Digitisation to enable all BLMK citizens, patients, carers, care providers, clinicians and managers to make maximum use of information to deliver the best outcomes with maximum efficiency; and to develop a population health capability and capacity to support proactive care management, and true strategic commissioning based on population health outcomes and care gaps.

• System re-engineering is the priority workstream overseeing the development of the ICS, understanding and developing the functions that should be in place at the level of locality, place and system. 

There are also four critical reviews supporting the functional design work programme, which is determining which functions are best located at the three different levels of the three-tier model. 

• The future configuration of NHS commissioning led by a BLMK joint commissioning executive working to align CCG governance and management, co-ordinate and rationalise CCG business-as-usual activities, and support the design and development of arrangements for strategic commissioning. It will also lead any structured public engagement exercise that will precede the formal adoption of such arrangements.

• The future harmonisation and integration of activities that span NHS and local authority boundaries both at a place (ie, local authority) level and on a wider BLMK geography to ‘help inform the approach to collaborative commissioning at the appropriate tier’. To support this, the four councils have also established a BLMK level ‘place’ joint scrutiny committee.

• The future organisation of secondary care across BLMK through the creation of a BLMK acute trusts integration steering board. This includes the chairs and chief executives of each of the three NHS trusts as well as further executive and non-executive director input. The aim is to create a single acute service, operating across the three hospital campuses.

• Improving services in BLMK – how the ICS will support, strengthen and accelerate the ability of partners to achieve key service improvement deliverables for 2017/18 and 2018/19. 

Stakeholder engagement

The ICS has developed engagement groups, which now include the BLMK staff voice partnership, BLMK public voice partnership, the BLMK general practice voice, the system Healthwatch group, the joint health overview scrutiny committee and the BLMK trade union partnership, in developing its work. There is also an aspiration to increase involvement of NHS non-executives, elected council members and the public through the development of the BLMK leaders and chairs STP board.

The recently formed clinical executive group (including medical and nursing directors of the 15 organisations, and GP leads) and a BLMK clinical congress are supporting engagement with all key stakeholders. The latter is an open event (including to the public) and takes place four times a year. It is an opportunity for engagement and informal networking with and between the range of individuals involved in governing, working in or receiving services from one of the partner organisations within the ICS.

Key enablers

The features that have facilitated progress in BLMK include the following.

• A resourced programme management office – staffed through secondments from all organisations involved in the work, which has resulted in the development of a single operating plan, with chief executive commitment and focused priorities. This office is now supported by NHS England regional resource, supplemented by NHS England ICS experts.

• System chief executives acting as senior responsible officers for each of the priority programmes and supporting enablers. 

• Fortnightly chief executive meetings, where there is peer-to-peer support and accountability for programme delivery. 

• A strong sense of place (defined by local authority areas) with a focus on integrated delivery and commissioning for the four populations, the development/enhancement of the four place transformation boards, and embryonic establishment of a provider alliance.

• A commitment to transformation, specifically across historic organisational boundaries, with each organisation having its own internal transformation capability and the ICS adding to that with system-wide transformation capability. 

• Analysis of the data to support the development of new models of care.

• The ICS lead is a local authority representative and has been able to provide a co-ordination and brokerage role for the NHS organisations, and focus on outcomes for the local population.

Next steps

Many interviewees commented that delivery of changes that patients and staff would notice was key to demonstrate progress by the ICS. Developing primary care networks in multiple locations was seen as one way of fulfilling this need. In addition, spreading examples of good practice that exist in some areas more widely across the ICS is enabling developments in complex care, care homes and social prescribing, and is identified as a mechanism to be adopted to continually support informal and formal partnerships/collaborations of areas of transformation, to create a self-sustaining learning system. 

A key challenge for the work in BLMK is managing the balance between place and scale – the two top tiers of the ICS. The place-based working is developing specifically around the improved service offer to complex care patients in all four of the places, using national transformation money. System-wide risk and gain share arrangements are pivotal in this work, while social prescribing will become embedded within each place, supporting the de-medicalisation of non-medical issues. There is also a functional review of commissioning under way while the chief executive group is starting to focus on 10-year planning, incorporating new national direction with that of local authority planning. 

There is more work to do to determine the role and respective priorities at both system and place levels and, while there have been discussions about the footprint itself, the current focus is on creating integration between local authorities, providers and commissioners. Finally, improving governance was seen by some interviewees as important to help facilitate timely decision-making.