The independent review of integrated care systems (ICSs) led by Patricia Hewitt, published earlier this month, reinforces the crucial role that ICSs have to play in prevention of ill health. But while there is widespread agreement that this is important, what has sometimes been less clear is exactly what that role should look like, and how it is distinct from the role of local authority public health teams. It’s a key question as ICS leaders grapple with the wider issue of what should happen at system, place and neighbourhood level. Recent examples from tobacco control highlight how ICSs can complement and reinforce work at other levels and help deliver potentially significant population health benefits by doing so.
Effective tobacco control is essential if ICSs are to achieve their goals in relation to inequalities. The Marmot Review reported that smoking accounts for approximately half of the difference in life expectancy between the lowest and highest income groups in England. Smoking cessation contributes to all five of the key clinical areas identified as priorities in NHS England’s Core20plus5 approach to reducing health care inequalities. Smoking also has a substantial impact on the NHS – data indicates that more than 400,000 hospital admissions per year in England are attributable to tobacco. So how can ICSs help support the government’s goal of making England smokefree by 2030?
Tackling tobacco in Humber and North Yorkshire
A tobacco control programme recently launched by the Humber and North Yorkshire Health and Care Partnership provides an example of how partners might work together at system level to increase their collective impact. The programme is a partnership between the NHS and local authorities aiming to work with voluntary sector organisations and academic bodies to accelerate reductions in smoking rates and to become a centre of excellence for ICS-level tobacco control. By working together, the organisations involved intend to co-ordinate their activities more closely, including through a range of population-level interventions such as tackling illicit tobacco, mass media campaigns and joint advocacy for effective national policy. There will be action to ensure there is consistent stop smoking support available across the ICS with equitable access to nicotine-replacement and e-cigarettes (as quit aids). There will also be support for local authorities to deliver targeted interventions to specific communities. Humber and North Yorkshire Integrated Care Board (ICB) is drawing on health inequalities funding from NHS England to finance its contribution to the programme, and this will add to the funding earmarked by public health teams rather than substituting for it.
System-wide action on tobacco is also gaining momentum in some other ICSs. For example, North East and North Cumbria ICB has committed to use NHS money to match-fund the investments made by local authorities in tobacco control, again drawing on health inequalities funding to do so. This funding is being used to provide ongoing support to an evidence-based regional approach in the north-east, Fresh, that has seen the largest reductions in smoking rates in England since it was introduced in 2005.
What’s the role of ICSs in prevention?
Returning to the broader question of the role of ICSs in prevention, these examples illustrate some of the ways that working together at system level can add value to wider efforts. Particularly noteworthy is the fact that the role of the ICS in these programmes is not limited to thinking about the contribution of health care services, but is conceived much more broadly. Specific roles for system-level leadership include:
bringing together the resources and expertise held across the NHS, local government, voluntary sector and other partners
enabling partner organisations to take co-ordinated, mutually-reinforcing action and reducing duplication
supporting consistency of approach and reducing variation in access to services
aggregating skills and creating a central hub of expertise to help drive up effectiveness
accessing new or different funding streams and using these to increase total investment in prevention
enabling partners to speak with a stronger collective voice to amplify their impact on wider policy.
There is also an opportunity for ICSs to take a more integrated approach to prevention, supporting approaches which tackle multiple risk factors simultaneously. Doing so would play to the strength of ICSs as system-wide partnerships.
What’s needed now?
Thinking longer term, a key challenge ahead is to ensure that funding for preventative initiatives is sustainable rather than relying on time-limited funding pots. While the examples above make use of health inequalities funding from NHS England, ultimately the strategic direction needs to involve ICBs shifting core resources towards prevention as part of a reorientation of spending. This is one of the core recommendations of the Hewitt Review.
The role of ICSs in prevention does not replace the need for more local action in places and neighbourhoods based on a detailed understanding of the needs and assets of different communities (as highlighted by our forthcoming work on the role of district councils as partners in ICSs). However, the evidence from regional tobacco control strategies is that areas with mechanisms to support collaboration across larger geographies have made faster progress than those without.
By supporting integrated, system-wide approaches to prevention – not as an alternative to locally led action but as a complement to it – ICSs can help bring about health improvements at greater scale. Given the impact of the cost-of-living crisis and related pressures on people’s health and wellbeing, collaboration and co-ordination across systems is much needed to increase the impact of all involved.