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Evidence and consultations

The King’s Fund submission to the Public Accounts Committee inquiry on progress in establishing integrated care systems in England

The King’s Fund welcomes the National Audit Office’s recent report assessing the starting point for ICSs and the challenges and risks to their achieving their objectives. The King’s Fund has strongly supported moves to better integrate care and improve population health over many years and has broadly supported the reforms introduced through the Health and Care Act 2022.

However, we also recognise that these changes have been enacted at an incredibly challenging time and that making progress towards the objectives of ICSs in this context will not be easy. The National Audit Office report underlines the scale of these challenges and the significant risks to ICSs achieving the objectives that have been set for them.


  • There is much to welcome in the introduction of integrated care systems (ICSs). However, they have taken up their formal role at a time of unparalled operational challenges for health and care and making progress towards their objectives in this context will not be easy.

  • To avoid setting up ICSs to fail, the asks of integrated care boards (ICBs) will need to be commensurate with their resources and starting points, and measures used to assess their performance should be balanced, proportionate and realistic. It is also important that ICSs are able to engage in realistic planning processes, and that these are not undermined by unrealistic efficiency assumptions (as happened in some systems when sustainability and transformation plans where first produced in 2016).

  • ICSs cannot be expected to quickly overcome fundamental issues such as those caused by years of inadequate workforce planning or by chronic underinvestment, most notably in social care. They can certainly play their part, but while local measures should help, national action is sorely needed on these and other issues.

  • Leaders from the NHS and local government have played a major part in shaping the development of ICSs to date, resulting in a high level of support of and commitment to the reforms. Going forward, it will be important for leaders in the national bodies to work alongside ICSs in ways that continue to support this, and to avoid undermining the sense of local ownership that underpins the partnership-working ICSs are attempting to nurture.

  • Current pressures risk driving a narrow focus on acute sector waiting times at the expense of work to prioritise prevention, population health and reducing inequalities, and there are concerning indications that ICSs are already finding they have little resource to dedicate to this work. However, local systems will not be able to realise ambitions to put services on a more sustainable footing or support a healthier, more productive population if they do not give greater priority to prevention and population health.

  • The integration taking place within local systems needs to be mirrored at the national level with NHS England working closely with the Office for Health Improvement and Disparities, the UK Health Security Agency, the Department for Levelling Up, Housing and Communities and others to join up initiatives that have the potential to improve health and wellbeing.