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Are local authorities equal partners in statutory integrated care systems?

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Partnership working between local government and the NHS has come a long way in recent years. Back in 2016, when some of my colleagues first began delving into the inner workings of sustainability and transformation partnerships – the precursors to today’s integrated care systems (ICSs) – the picture was not always pretty. Many local government leaders told us that they felt little ownership over the system plans to which, at least nominally, they were partners. One said that ‘the majority of chief execs in [our area] just think it’s a joke’.

Compare that with the words of another local government leader involved in our new research, conducted since ICSs took on their statutory form this summer: ‘Do I think the ICS is a force for good and it's something we should be doing? Absolutely.’ There continue to be some critics, of course, and areas where relationships are still challenging. But by and large, our research suggests that local government is much more positive about these latest reforms than previous incarnations.

To some extent this is unsurprising – local government leadership is now hard-wired into the structure of ICSs in several novel and significant ways. Each ICS includes an integrated care partnership (ICP) responsible for developing an integrated care strategy, and most of these have a local government figure as their chair (often an elected member). The other key structures in ICSs are the new integrated care boards (ICBs) that are now responsible for NHS resources and performance. These are legally required to have local government representation on their boards, and public health teams, social care teams and others are playing integral roles in the programmes of work that ICBs are overseeing.

'These are still early days for statutory ICSs and there lies ahead some extremely challenging terrain that could put partnerships under significant strain.'

Before we celebrate this progress, however, a note of caution. These are still early days for statutory ICSs and there lies ahead some extremely challenging terrain that could put partnerships under significant strain. Foremost among these is the wider social and economic context – ICSs have been born into the mother of all storms, with deprivation rising rapidly in many communities and the health and care system struggling through its darkest months in decades.

In our research we found that although ICS leaders are strikingly upbeat about the opportunities created by the Health and Care Act, many are nonetheless deeply concerned that this wider context means it will be harder for ICSs to fulfil their potential in practice. In particular, if ICSs are compelled to focus too narrowly on addressing the immediate pressures in the NHS at the expense of the longer-term challenges involved in shifting to a more preventative approach to health or taking system-wide action to tackle health inequalities, then local government partners may reasonably ask whether the significant time invested in ICSs is paying sufficient dividends.

Related to this is the complex issue of accountability. As custodians of NHS funding, ICBs are of course accountable to national government through NHS England. But the intention of the reforms is that they are also accountable to local government (and vice versa) through ICPs. Whether this local accountability has teeth remains to be seen. With ICPs agreeing their draft strategies this month, it will soon become clearer how willing ICBs are to take direction from ICPs, and how far their work reflects local priorities. The acid test, according to one ICB chair, will be ‘How much is the ICP going to be the ornamental part of the new arrangements and how much is it going to be an engine for change?’

'What will help ICSs stay true to the original vision of equal partnership? Our research suggests that ICB chairs have a key role to play role in this.'

These are important questions, which will be explored over the next two months by former minister Patricia Hewitt as part of her government-commissioned review of the oversight and governance of ICSs. In the meantime, what will help ICSs stay true to the original vision of equal partnership? Our research suggests that ICB chairs have a key role to play role in this, using the four purposes of ICSs set by NHS England to direct attention back to broader concerns. It’s also important for all partners in ICSs – including local authorities as well as providers – to be thinking in terms of ‘we’ rather than ‘they’ to avoid conflating the ICS (which is a shared endeavour) with the ICB (which is one player among many).

There is no doubt that there are tough times ahead for these relatively young partnerships. But if successful, they represent a fundamental and welcome shift towards a more integrated, place-based approach towards health and care. And in many parts of the country there is, for now, a determination to make these new arrangements work.

A version of this blog was originally published on the Local Government Chronicle website.