The Nottingham and Nottinghamshire integrated care system (ICS) covers a mixed urban and rural area, spanning communities with some of the highest and lowest levels of deprivation in the country. There are significant health inequalities between different communities.
Partnership working is well established, with arrangements in place that predate both the ICS and STP. This includes two transformation programmes: Greater Nottingham Health and Care Partners brings together partners across Nottingham city and south Nottinghamshire, building on the work of the Principia MCP vanguard; and the Better Together alliance in mid-Nottinghamshire builds on the work of the PACS vanguard.
When the ICS was announced, it was described as covering the whole of the STP with an initial focus on Greater Nottingham. While some of the early work of the ICS took place at this level, there is increasing consensus across the system that it should cover the whole Nottingham and Nottinghamshire STP area, with the two transformation programmes sitting below this as ICPs. Work is ongoing to develop a shared understanding between partners about where different functions should sit within these structures and how they will work together.
There are two large acute trusts (Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation Trust) and two main community and mental health providers (Nottingham CityCare Partnership works across the city, and Nottinghamshire Healthcare NHS Foundation Trust works across an area larger than that of the ICS). There are two upper-tier local authorities (the city council and county council) and six CCGs. Joint accountable officers and joint committees have been established to bring together the two CCGs in mid-Nottinghamshire and the four CCGs in Greater Nottingham. There are financial and performance issues within the system, with persistently poor A&E performance at Nottingham University Hospitals, and financial difficulties and a ‘requires improvement’ CQC rating at Sherwood Forest.
The ICS does not cover the whole of Nottinghamshire; Bassetlaw, in the north of the county, is part of the South Yorkshire and Bassetlaw ICS.
ICS structure and governance
The leadership team of the ICS meets monthly. Membership includes chief executives and accountable officers from the constituent NHS organisations, chief executives of the two county councils and clinical representatives from the transformation boards. A number of groups report into the board, including a clinical reference group, advisory group and finance group. There are several agreed system-wide programmes and supporting and enabling workstreams, which also report into the board.
The mid-Nottinghamshire and Greater Nottinghamshire transformation programmes each have their own boards, with supporting project management offices and governance arrangements. In mid-Nottinghamshire, this is underpinned by an alliance contract. The membership of these boards is broader than the ICS board and includes representation from non-statutory bodies such as third sector organisations, citizen advisory groups and patient representatives. Both report into the overall ICS leadership board.
As elsewhere, the governance arrangements are emergent and expected to evolve. A recent addition is an advisory and oversight group that includes chairs of NHS organisations and elected council members. There is an ongoing dialogue about how the ICS governance and two transformation boards should operate. On one hand, it is important to avoid duplication and ensure clarity about roles and responsibilities, while, on the other, it is important not to undermine progress or lose local sensitivity.
ICS priorities
The agreed system-wide priorities are to:
promote wellbeing, prevention, independence and self-care
strengthen primary, community, social care and carer services
simplify urgent and emergency care
deliver technology-enabled care
ensure consistent and evidence-based pathways in planned care.
Other priorities include developing a single clinical services strategy and work on housing, estates and the workforce.
Progress towards these priorities varies across the area. Many of the changes that have already taken place are a consequence of the vanguards. Changes include the introduction of integrated multidisciplinary teams to support people with complex needs in the community, GP hubs, targeted proactive interventions in primary care for specific patient groups, and enhanced clinical support for care homes. Both vanguards have reported positive evidence of the impact of their models, and much of the ICS’s focus will be on spreading these more widely. A significant element of the work in Greater Nottingham (and the principal reason for this area being the early focus for the ICS) is the development of a detailed understanding of population needs and service utilisation across the system through data and analytics.
Examples of progress: extensive care service
A major focus of the work in Greater Nottinghamshire has been to undertake detailed analytical work to better understand the local system. The ICS chose to engage an external partner (Centene UK) to support this work, utilising £2.7 million of ICS transformation funding.
The first stage of the process was a detailed actuarial analysis to understand user activity and costs in the system. This was then benchmarked against ‘well-managed systems’ (integrated systems considered to have best practice care models and supporting infrastructure) to identify opportunities for improving value. A key finding from the work was that it is difficult to draw meaningful conclusions about community, mental health and social care provision because of limitations in data quality and completeness. Another external partner, Bromley Healthcare, was engaged to work with the community health providers to improve their data.
Following the initial analysis, a second phase of work was undertaken to identify ‘design solutions’ to achieve the value opportunities. This included options for service change and infrastructure development. The 32 workstreams covered areas such as admission avoidance, population health management and IT. These were used to inform specifications for implementing new models, including the costs and capabilities required.
The next phases of this work are under discussion. There are a range of options, including building the capability to implement the proposals internally, commissioning support for specific elements, or entering into a long-term partnership with an external partner to act as a ‘system integrator’. The partnership with Centene has not been without difficulty, including concern from the local community and staff regarding the involvement of a private partner.
Stakeholder engagement
A number of pieces of work have been done to engage the local population in shaping the transformation agenda. Most of this predates the ICS. Several well-attended public events were held following the publication of the STP. More than 400 people attended these events and provided feedback on the plans, and further views were collected through an online survey. An update to the STP was published in July 2017, including a number of changes to the initial plan based on the feedback received from the public.
The ICS works closely with local Healthwatch organisations, which have provided support in planning and delivering engagement events. There is also a systems advisory group, which includes patient and public involvement leads from the constituent organisations. Additional engagement work has taken place at a more local level in the two transformation areas.
While interviewees were generally positive about the engagement work undertaken for the STP, they still identified it as an area where more work could be done, and some reported that these elements of the work have been less strong in recent months.
Key enablers
Features of the local system that have supported progress include the following.
A history of collaboration and partnership working in the two ‘transformation areas’, which meant there were strong local relationships and advanced local examples of integrated service models on which to build.
Respected and influential leaders driving forward the changes locally, including examples of strong local authority and clinical leadership.
Recent changes in local leadership were viewed by some as being helpful in bringing a fresh perspective on the system and driving further change.
Dedicated resource and capacity to work on the ICS through the secondment of a managing director from the NHS England regional team.
A good understanding of local population needs and system capabilities, developed through detailed analytical work.
Next steps
A key priority for the Nottingham and Nottinghamshire ICS is to develop further clarity about the role of the ICS and the two transformation areas. This includes exploring where different functions – particularly commissioning functions – should sit within the new system and taking steps to reduce duplication between the different levels of partnership working.
A key priority is to deliver on planned service changes and to continue to spread examples of good practice across the whole ICS. There are also decisions to be made about the nature of any further work with Centene, and what the nature of a relationship with any potential external partner might be.
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