Realising the potential of integrated care systems

Overview

• Integrated care systems (ICSs) were created to increase collaboration in the health and social care sector and to enable the NHS, local authorities and other partners to take collective responsibility for improving health outcomes, reducing inequalities, delivering better value for money, and driving local social and economic development.

• This research examines the development of ICSs by assessing their efforts to develop system-wide approaches to the recruitment, training and retention of staff. The findings are based on 24 in-depth interviews with local leaders in four case study sites plus a series of online workshops.

• There are clear signs that progress is being made. We found evidence of ICSs beginning to build a ‘whole-system’ approach to workforce, in which local organisations work together more closely to tackle shared workforce issues and develop new solutions that better meet the needs of the local population. Our research identified several specific ways in which ICSs are enabling this to happen.

• Despite these signs of progress, some of the more transformative work planned by ICSs is proceeding at a slower pace than intended as a result of the extremely challenging circumstances in which ICSs have been introduced. There is widespread concern that ICSs may not achieve their full potential unless more is done to create an environment conducive to their success.

• The behaviours of national, regional and local leaders will make or break ICSs. There is an urgent need to ensure that accountability arrangements drive behaviours that reinforce system working rather than undermine it. Success depends on supporting people at all levels to think, plan and act in ‘system-focused’ ways.

Why we did this research

Integrated care systems (ICSs) are part of a decade-long shift in the English NHS from an emphasis on competition between organisations to a greater focus on collaboration and partnership working. This has been driven by a recognition that people using health and social care services increasingly need support from multiple parts of the system and that this support needs to be joined up and co-ordinated more effectively. ICSs bring together NHS bodies, local government, voluntary sector organisations and others to plan how they can collectively meet the needs of local people and help create the conditions for healthier lives.

Major national reforms gave ICSs statutory powers and budgets for the first time in July 2022. Two years on, we wanted to examine how ICSs have been developing since these reforms were introduced. In particular, we wanted to understand the extent to which ICSs are helping local leaders to develop ‘whole-system’ solutions to some of the substantial challenges facing the health and social care system. We chose to focus on workforce issues because these have a significant impact on patient care and often require a co-ordinated response from multiple organisations of the kind that ICSs were designed to enable.

What we did

We wanted to understand the development of ICSs through the eyes of people involved in the workforce agenda, exploring the successes and challenges they have encountered in attempting to work collaboratively on workforce issues such as the recruitment, retention and training of staff. We did so by selecting four ICSs as case studies and interviewing a range of people in each site. In total, we interviewed 24 people, including leaders with responsibility for workforce in integrated care boards (ICBs), provider trusts and the social care sector, as well as voluntary sector leaders and representatives from local Healthwatch organisations. We also tested and refined our findings through a series of online workshops.

What we found

What progress have ICSs made?

Overall, we found that ICSs have made progress in supporting local organisations to work together in a more collaborative way on workforce issues. However, this progress has been uneven and has not come easily. The two years since ICSs were given statutory status have been among the most challenging the NHS has ever faced, and it was evident in our research that these challenges have sometimes impeded ICSs’ efforts to develop innovative workforce solutions.

For example, several sites reported that the need to focus on resolving immediate issues, such as staff shortages, has meant that they have made slower progress on some of their more transformative partnership work aiming to redesign the workforce for the future. Managing the redundancy processes triggered by the national requirement to reduce management costs by 30% has consumed a significant amount of time for workforce teams in ICBs, while industrial action during 2023 and 2024 has meant that their counterparts in NHS trusts have often been focused on maintaining safe staffing levels.

We found that ICS leaders have had to navigate a series of tensions as they attempt to work in a ‘system-focused’ way (see Figure 1), adding to the complexity of the task they face.

How are ICSs helping to address workforce challenges?

Despite the difficult circumstances, we found that ICSs are beginning to help local partners build a more ‘whole-system’ approach to workforce. Our research identified six distinctive ways in which ICSs are adding value:

• organising around a shared purpose

• building system leadership

• encouraging system-focused behaviours

• scaling and spreading success

• using resources more effectively

• managing complexity.

Much of the work done in these six areas goes largely unseen. There have been visible changes – for example, shared approaches to recruitment, training and staff wellbeing; the introduction of new roles or new pathways into the health and care workforce; and the extension of training opportunities to staff outside the NHS. But, importantly, changes such as these have been underpinned by the largely invisible efforts of local leaders to strengthen relationships, change mindsets, and encourage different behaviours within their system. This unseen work is vital and needs to be valued accordingly.

Our report describes how ICS leaders can perform these six functions in practice, and the challenges that some are encountering in doing so.

How can national bodies support ICSs to succeed?

Our research found that there is a risk of ICSs going ‘off track’ as a result of pressures on services, intense political scrutiny, and extremely difficult economic circumstances – and the effects these conditions are having on the behaviours of leaders locally, regionally and nationally. Interviewees in our case study sites highlighted three things that policy-makers and national bodies could do differently to help ICSs maximise their impact:

• Be realistic about how fast ICSs can be expected to demonstrate progress on workforce and other objectives, given the challenging context they are operating in. Many interviewees argued that they would need more time and a period of stability before they would be able to fully realise the potential of ICSs to deliver innovative workforce solutions.

• Ensure that the frameworks and behaviours used to hold ICSs to account are proportionate, and reinforce local partnership working rather than undermine it. Some interviewees suggested this should include strengthening local accountability arrangements, such as peer-to-peer challenge, as a complement to national accountability.

• Give systems greater flexibility to use national funding in ways that best serve their local needs and priorities. Interviewees argued that this is likely to deliver greater impact from the resources available and would help to strengthen the local partnership working on which the success of ICSs depends.

What next?

Much of what we heard from leaders in our case study sites was in line with the recommendations of the Hewitt Review and we would strongly encourage the new government to return to those recommendations. In addition, we set out four actions for national, regional and local leaders that would give ICSs the best chance of success.

• Maintain a clear focus on long-term transformation. In addition to the changes from national bodies described earlier, this will require ICS leaders to strengthen the infrastructure and skills needed to drive improvement and change across their local system.

• Practise system collaboration and invite challenge. This involves being prepared to be challenged and to challenge behaviours that are not in line with the principles of system working, paying attention to power dynamics and making efforts to counterbalance the dominance of the NHS in system working.

• Grip tight on outcomes, loose on means. As proposed by Hunter and Bengoa, integrated care requires leaders to be clear about the outcomes being sought but to allow flexibility over the means through which those outcomes are achieved. This requires a more enabling approach to accountability and regulation, as described earlier, as well as delegation of powers to place-based partnerships within ICSs.

• Value the views of local people, patients and staff. We suggest that the most powerful way to gain insight into whether integrated care is making a difference is to understand what it feels like working in, or being cared for by, the system. As part of this, ICSs need to work more closely with people and communities to understand their experiences and priorities. Systems also need to be able to measure progress from the perspective of people who use services.

It is early days for ICSs, and there is clearly more work to be done to ensure that they deliver improvements for people using health and care services and the wider population. In the current context, the worst possible policy choice for national government would be to lose patience with ICSs and embark on an alternative set of structural reforms. Instead, it is time to focus on how people at all levels can be supported to work differently to allow ICSs to achieve their full potential.