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Integrating health and social care has been an objective of national policy for more than three decades but has started to gather pace with the introduction the Health and Care Bill, which is expected to put integrated care systems (ICSs) on a statutory footing from April 2022. Statutory ICSs will comprise two key bodies – an integrated care board (ICB) and integrated care partnership (ICP).
ICBs will take on the NHS planning functions previously held by clinical commissioning groups. Each ICB will produce a five-year plan for how NHS services will be delivered to meet local needs and this plan must take account of an integrated care strategy, setting out how the wider health needs of the local population should be met.
This wider strategy will be developed by the second key body – the ICP. ICPs are statutory committees bringing together the NHS, local authorities and other organisations, including those from social care, as equal partners to focus more widely on health, public health and social care.
ICSs are intended to promote equal partnership between the NHS and its wider partners, including local authorities and social care, but the history of previous attempts at integration suggests there is a risk that the NHS will dominate. Within social care, there is a particular concern among providers that they will be left ‘outside the tent.’
This practical guide, supported by Home Instead UK, aims to encourage partnership-working between NHS and social care stakeholders as ICSs develop. The suggestions it contains are based on The King’s Fund’s work with ICSs and a roundtable discussion, held with Home Instead UK, to explore these issues with stakeholders working in and with the social care sector.
The work for this project was funded by Home Instead UK. The information included here was independently researched, developed and written by The King’s Fund.
Key issues - The King's Fund analysis
The work outlined above has some key messages for adult social care and its partners in ICSs.
ICSs offer real potential for partnership with the NHS and other sectors.
ICSs are an opportunity to develop genuinely joined-up, personalised care.
There is a need for clarity about structures and systems…
…but leadership and culture are critical.
Resources are a key challenge so making best use of them is essential.
It’s important to assess and measure the right things.
We discuss each of these in more detail below. Overall, it’s clear that ICSs offer real opportunities for social care commissioners and providers. There is a potential for stronger, more equal partnerships and greater influence, which could improve the range and quality of support provided and therefore, most importantly, the lives of people who draw on them: which is, after all, the ultimate point of ICSs. There is also the potential for learning between sectors and for developing meaningful, cross-sector strategies on issues such as workforce.
There are also challenges. There are differences in language, spending power, metrics culture and leadership style. The history of joint working between the sectors is patchy at best. Yet the prize of better, more joined-up care for the individual and the wider use of preventive approaches to population health is huge.
How an ICS comes together, and how social care exerts influence within it, will differ between ICSs but there needs to be strong social care voices on ICSs’ system-level decision-making forums (the ICB and ICP). In addition, local authorities and social care providers need to be embedded in decision-making forums at place and potentially neighbourhood-level because it’s at those tiers that the real operational change will be led.
It will be important to ensure that ICSs have the full breadth of the social care sector on their agenda, including children’s services, mental health and disabilities.
Often what has happened in conversation so far is that we've just invited the directors of adult social services and thought that covers social care. It clearly does to some extent but, hang on, what's going on in children services, mental health, learning disabilities, physical disabilities, and also, crucially, for users and carers.
Dame Suzi Leather, Independent Chair, Integrated Care System for Devon
Social care providers – large and small, private and voluntary sectors, serving self-funding as well as council-funded clients – have vital experience and understanding. How to involve them will again differ across ICSs, but we heard of options including through provider associations (though these don’t exist everywhere and are local rather than ICS-level bodies) or by including a social care-focused non-executive director on the ICB. Systems will have to gauge how to most effectively engage social care without creating additional layers of bureaucracy and risk becoming ‘talking shops’.
However social care is involved, it shouldn’t undersell itself. Social care and local government have strong history of mobilising assets around the needs of the individual and tackling inequalities. They have wide experience of engaging with communities and have proven expertise in working within constrained budgets. They bring this strength to ICS partnerships. This experience, along with the work of ICSs to involve local communities and service users more directly, should help ensure that the voice of those who draw on social care services is heard and listened to.
Ultimately, social care is a critical part of a health and care system, employing as many staff as the NHS and having a huge reach of services. An ICS that fails to engage with the sector will lack credibility and legitimacy. Failing to engage the sector effectively will make the aspirations of ICSs – to genuinely improve services for local people – extremely difficult, if not impossible, to fulfil. That’s a message that needs to be reinforced.
The views of health and care leaders
There is real potential for partnership between social care, the NHS and other sectors
There must be mutual understanding of who does what best in the system. It will take more than social care partners simply being involved in decision-making bodies. Social care needs to be on the agenda, not just in the room.
As well as understanding each partner’s capabilities, there also needs to be a collective responsibility around resolving joint challenges. Social care representatives can act as healthy ‘disrupters’ if they and the NHS work together to offer joint solutions.
The partnerships require alignment of priorities, resources, and purpose. It’s about focusing the skills and budgets from all partners, including social care and the NHS, on the needs of the individual.
A good ICP needs genuine partnership between all partners. A whole-system population health approach is needed. Care will differ at place depending on the needs and wants of the local population, following a principle of subsidiarity.
Although variable across England, the role of care associations in giving a voice to providers is a good place to start to work with the ICPs. There is a role for the associations to extend their network to all social care providers to ensure they are representing everyone in the sector to the best of their ability, as well as an investment in upskilling to support those who currently don’t have access to platforms to have a meaningful voice.
If there is follow through on the intentions – and it's a big if – there's a prospect, there’s an opportunity to make a stronger and more equal partnership with a wider range of partners involved and having an influence.
Sarah Pickup OBE, Deputy Chief Executive, Local Government Association
ICSs provide an opportunity to develop genuinely joined-up, personalised care
Personalised care can mean different things to different people but a frequently-used definition is that it is about ensuring ‘people have choice and control over the way their care is planned and delivered. It is based on “what matters” to them and their individual strengths and needs’.
With the development of ICSs, there is an opportunity for both health and social care partners to focus on what works for the person accessing services, not around who works for which team and whose budget incurs the cost. Social care has an important part to play in delivering better health and wellbeing for the population alongside the NHS.
Fluidity around the person is crucial to delivering integrated care. Rigid structures can act as a barrier to delivering integrated care: care needs to move around and change as people’s needs change.
People using services and their carers, frontline staff, smaller flexible providers, and private providers offer unique ‘on-the-ground’ insights, expertise, and solutions. There needs to be space to channel this local and frontline insight and intelligence into broader ICS discussions.
It's all about making sure that services join up around the individual: they are the sole judge of whether integration is working or not. If a user doesn't feel that services are integrated, then they aren’t integrated and we need to give that some primacy in the way that we consider how well services are working together.
Jacob Lant, Head of Policy, Public Affairs and Research, Healthwatch England
The starting point is around person-centred care and trying to make sure that this is the strongest narrative, both through the ICP and the ICB. Because when you come back to people, you come back to the principle of everyone being focused on the same thing, whereas otherwise it becomes an organisational focus.
Rosie Seymour, Programme Director, Better Care Fund
There is a need for clarity about structures and systems...
In any given area, it is important that there is a clear understanding of the respective roles and responsibilities of ICBs, ICPs and health and wellbeing boards. Without this, there is a risk of duplication, conflict or inaction as a result of unclear roles.
There is a need for clarity around how the ICB makes decisions, receives information, engages with local communities, and ensures that challenges are managed with transparency. This will involve having a clear pathway between ICPs and ICBs for effective action, for ICPs to offer the space for a genuine partnership between NHS and local authorities, and ensuring that the ICP has influence over ICBs.
There are some key questions about these formal structures in practice. Whether there will be the same chair for both ICB and ICP will be decided locally. Is consistency across these elements of ICSs important or would there be an opportunity to create a healthy challenge between the two? What is the role of social care providers within these partnerships?
Behind the differences, the key ‘connective tissue’ across all structures is the narrative and delivery of person-centred, joined-up care.
The reality is the [ICB] is where the decision-making will take place, so we need to have some really clear views about what the board gets in terms of its information, how it engages its communities, how it makes sure that – if there are going to be challenges to what they want to achieve – what do they do as a board to make sure those challenges are dealt with.
Professor Martin Green OBE, Chief Executive, Care England
Getting the right partners around the table is critical for good integration so that everybody feels they've got a voice, including people who use services and people who deliver them, because they're the experts we often ignore.
Melanie Weatherley MBE, Co-Chair, Care Association Alliance
...but leadership and culture are critical
The approach to change adopted by ICSs must be different to previous models of integrated care to achieve a different outcome. This won’t be achieved through imposing new structures, but through organisational development and culture change.
The development of ICSs offers an opportunity to pivot leadership towards more flexible, bottom–up approaches that improve services for people and communities.
However, ICS leaders will need to maintain focus on that goal if they are to overcome the challenges and potential barriers they face.
There’s evidence that this cultural change – to work in genuine partnership – has started. ICS leaders in some areas have started to prioritise social care, but there is still work to do.
We need teams and workforce that are empowered to focus on what works and not who employs them or where the boundaries lie.
Sarah Pickup OBE, Deputy Chief Executive, Local Government Association
We want more ‘can do’ and less ‘yes, but…’ and no blame.
George Coxon, Lead for Devon Care Kite Mark, elective member for Integrated Care System Collaborative Board, Eastern Devon representative for Provider Engagement Network Reference Group
For me, we need cultural change because otherwise we are going to be here in 10 years’ time discussing the same things about different boards that fail for different reasons. We can't keep on moving deck chairs around on the Titanic; we need that real cultural change.
Martin Jones, Chief Executive, Home Instead
Resources are a key challenge so making best use of them is essential
The NHS faces significant challenges, while the precarious state of local government finances has left social care close to breaking point. ICSs create an opportunity to rebalance the partnership between NHS and local authorities, with both parties having an equal influence on decision-making despite differences in resources.
If systems are serious about taking a population health approach, ICSs need to be thinking about the role of spending across housing, transport and leisure services, not just NHS and social care, to tackle the social determinants of health.
The Covid-19 pandemic has driven innovation in addressing longstanding issues, shining a light on how integration can work well when funding is invested and budgets are pulled together.
There will be something for the NHS, with a larger budget, to learn from local government and the voluntary sector, which have had to operate with more limited resources.
It is not just budgets that are an important resource for partnership-working. The skills held by each team, as well as better data, also need joining up.
I think we've got really skilled at how to make the best use of assets and budgets, integrated around a person, and that certainly is something I think health systems can learn from local government.
Melanie Brooks, Corporate Director, Adult Social Care and Health, Nottinghamshire County Council
It's important to measure and assess the right things
Within the new structures, there will inevitably be a focus on performing well against assessment criteria. A key question is what ICSs should be measured and assessed on.
There could be potential tension between top-down performance management of the ICB and the more bottom-up, participative ICP. What will be measured is likely to drive ICS direction and focus. There is a real concern that metrics focused solely on NHS performance management, such as reducing the backlog of elective care, will be shapers of agendas and behaviours.
Regulation offers the opportunity to do things differently, to change the focus from organisation and process to outcomes and people. The role of the Care Quality Commission should be to evaluate whether the objective of ICSs – to deliver better integration, population health, and prevention – is being met.
When developing system objectives, transparency is key, leaving a clear, public trail to resolve any potential challenges.
We have to reframe the metrics that we're going to be judged by. They will shape the way we behave and if we don't get the right ones, we will behave in the way we've always behaved.
Rt Hon Prof Paul Burstow, Independent Chair Hertfordshire and West Essex ICS, and Chair Designate, Integrated Care Board
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