A year of integrated care systems: Buckinghamshire

The Buckinghamshire integrated care system (ICS) covers the relatively affluent county of Buckinghamshire, which is split into seven localities. The health and life expectancy of its population are better than the England average. However, there are some areas with higher levels of deprivation, particularly within Aylesbury Vale. 

The Buckinghamshire ICS is one of the smallest of those in the first wave, covering a population of approximately 540,000 and comprising six organisations. These include four provider organisations: Buckinghamshire Healthcare NHS Trust, an integrated acute and community service provider; Oxford Health NHS Foundation Trust, a provider of mental health services; South Central Ambulance Service NHS Foundation Trust; and FedBucks, a GP federation which covers 85 per cent of the 52 GPs practising within the ICS area. The ICS also includes Buckinghamshire CCG (NHS Aylesbury Vale and NHS Chiltern CCGs merged formally in April 2018), and Buckinghamshire County Council, a single upper-tier authority. The South, Central and West Commissioning Support Unit is a supporting partner to the ICS. 

Buckinghamshire ICS is one of the few ICSs established across an area which is smaller than the STP footprint; like Berkshire West ICS, Buckinghamshire ICS sits within the Buckinghamshire, Oxfordshire and Berkshire West (’BOB’) STP footprint. The accountable officer for Buckinghamshire CCG has been appointed interim chief executive and accountable officer for Oxfordshire CCG, the third area within the BOB STP.

ICS structure and governance

Buckinghamshire ICS’s governance structure includes an ICS partnership board, consisting of chief executives and accountable officers from each of the member organisations. The board meets monthly and reports to the health and wellbeing board as the statutory body responsible for setting the system's health and wellbeing strategy. 

Below the ICS board there is the ICS leadership executive, comprising director-level representatives from each of the constituent organisations. This oversees the development of the ICS’s workstreams, and is responsible for tactical decisions. There is also an ICS directors of finance group, comprising the directors of finance of the member organisations. This group meets fortnightly and reports to the executive body. An ICS programme delivery group is being created, which will report to the leadership executive, with responsibility for delivering a number of care model and enabler workstreams. 

An integrated commissioning executive team has been established, which has delegated responsibility for all joint commissioning between Buckinghamshire County Council and the CCG. In 2017, a provider collaborative was also established, bringing together provider organisations to deliver integrated care (for example, in urgent care and mental health). 

To date, there has been little in the way of dedicated ICS resource; however, the ICS has recently appointed a managing director – a role funded from transformation funds, with no affiliation to any of the member organisations. The intention over the longer term is to establish a shared portfolio office and system transformation team.

Alongside the strategic governance structure is a well-developed clinical governance structure, with a dedicated clinical director for the ICS. The aspiration is to build a single clinical leadership network across all organisations and at all levels. 

However, as is the case in many of the ICS areas, the governance arrangements for the Buckinghamshire ICS are still being developed. For example, the ICS is also in the process of establishing an engagement group, which will be chaired by Healthwatch and part of the formal governance structure. 

ICS priorities

The ICS’s transformation programme is made up of four ‘pillars’ as follows.

• Population health – segmenting populations, determining their needs and monitoring the outcome of interventions. 

• Integrated care – improving access to services, particularly for those with long-term conditions or living with frailty. 

• NHS five year forward view priorities – national priorities, including those in cancer, primary care, urgent care and mental health. 

• Professional support services – ensuring that enablers such as technology are in place to allow the ICS to operate effectively. 

The Buckinghamshire ICS’s Integrated Operations Plan 2018–19 highlights progress in each of these areas. There has been particular progress on the integrated care pillar, with the development of community care hubs and Buckinghamshire integrated care teams. There has also been progress in primary care, where the ICS is building on a primary care strategy developed in 2015, supporting the development of primary care clusters and improved access to GP services. 

Stakeholder engagement

A number of activities have been carried out to engage local people in the work of the ICS. Some of this has been led by local authorities, including a series of ‘big tent events’. Buckinghamshire Healthwatch has also played a role, providing the public with information on the ICS through newsletters and other channels, and by championing the patient voice at an ICS level. To date, much of the engagement with the public has focused on service models (rather than the ICS structure), as this is seen as being most meaningful for local people.

The ICS has also been active in engaging staff in the system and the changes taking place within each organisation. As well as involving staff in shaping the ICS’s clinical strategy, engagement activity has promoted joint working between organisations. The CCG, Buckinghamshire Healthcare NHS Trust and Buckinghamshire County Council have developed a shared communications resource to help ensure consistent messaging around the ICS, and staff events have brought together health and social care staff from across the ICS to help them understand one another’s roles more clearly. 

Key enablers

The development of the ICS in Buckinghamshire has been supported by:

• the ‘simplicity’ of the ICS geography, including the coterminosity of the CCG and the local authority

• establishment of a provider collaborative, with a commitment from the key providers to deliver joined-up care 

• the commissioning approach – joint commissioning across the NHS and the council and, through working with the provider collaborative, a strategic approach to commissioning 

• transformation funding, which supported the development of the provider collaborative 

• shared projects around key back-office functions and estates. 

Next steps

A number of interviewees highlighted delivering planned service changes as a key next step. This means fully delivering on the change programme and ensuring that this is aligned with the ICS’s financial plans. Over the next year, Buckinghamshire will have a particular focus on managing its challenging financial position, delivering integration of services to improve efficiency and reduce costs within the system.

The ICS is also planning to further develop its governance arrangements, including strengthening management oversight and reporting. It aims to progress plans for a shared portfolio office in order to support genuine system working.