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Leading for integrated care

'If you think competition is hard, you should try collaboration'


  • The NHS long-term plan has reinforced the role of integrated care systems (ICSs) in establishing more collaborative working and joined-up care for patients and their local populations. ICSs will cover the whole of England by 2021.

  • As these systems evolve, strong leadership is needed to bring NHS, local authority, private and third sector organisations together.

  • Our interviews with the chairs and leads of both ICSs and the remaining sustainability and transformation partnerships (STPs) found that while progress is being made, there are also a number of challenges.

  • These leaders are clear about the skills needed to create an ICS, but issues around governance, accountability, whether legislation is needed and the pipeline of future system leaders remain.

  • System leaders also have concerns about future relations with ‘the centre’ and the regulators, the pace of change and on how far a collaborative and voluntary approach can be the key to success.

The context

'If you think competition is hard, you should try collaboration.'

This quote from an integrated care leader says it all. Under current plans all parts of the NHS in England are meant to have created an integrated care system (ICS) by April 2021. Better integrated care requires the dilution or destruction of the long-standing barriers between hospitals, GP practices, community services and social care, with the health system also working far more effectively with local government in tackling the broader determinants of population health. Getting there requires system leadership: the creation of collective leadership across all of that, for the benefit of the whole.

These new systems, however, are having to be constructed locally by ‘coalitions of the willing’, to use the phrase from the chair of one of the sustainability and transformation partnerships (STPs) that have been (and in many cases still remain) the pre-cursors of an ICS.

No-one can really tell anyone to do anything in the construction of these systems. And ICSs are having to be created within the constraints of the 2012 Health and Social Care Act, which sought to set in stone a ‘competition and choice’ model of NHS management that many now see as an obstacle to better integrated care.

About the report

This report reflects the views of 16 chairs and leads of both STPs and ICSs on the challenges involved. It looks at seven key areas.

What skills are needed to create an ICS? What authority do they have? To whom do they feel accountable?

Many interviewees reflect the views in a previous report by The King’s Fund, The practice of system leadership: being comfortable with chaos. The skills include being able to walk in others’ shoes, being committed to the place, not just the institutions, and building the evidence base to persuade others of the need for change. Many saw previous experience of managing complex relationships and systems as vital. But there was less clarity about to whom chairs and leads feel accountable.

Does moving from an STP to an ICS help?

‘Yes’ is the short answer. Some places have dropped the title ‘STP’ because it had become something of a ‘toxic’ brand.

What about relations with local government and others?

As a very broad generalisation (there are exceptions), these seem to be improving. It is plainly easier to become an ICS in some places than others because of a mix of geography and local politics. The move has started to bring a renewed focus on population health, and relationships with local authorities are a key part of that. Interestingly, authorities that are under different political control in the same STP or ICS have in places found it easier to work together than where neighbouring councils are under the same political control. The level at which councils engage – whether it be the leader, cabinet member for health or at official level – varies widely. For reasons that are good and less good.

What about governance, reorganisation, and relations with the centre?

All STPs and ICSs have a board but their size, composition, relations with substructures, and degree of transparency vary enormously. Board membership is often repeatedly revised, with that in itself reflecting the difficulty of constructing an all-embracing partnership. An issue of increasing concern is whether ‘the centre’ will continue to allow integrated care to be constructed locally, or whether it will take a more directive approach. Allied to that is a big question about how far STPs and ICSs should become the performance managers for their areas as opposed to merely being the planning and implementation bodies.

How far can this go without legislation?

Many say it can go a long way, or quite a long way. There is a fairly broad welcome for the legislative changes around procurement and joint committees that the outgoing administration and NHS England and NHS Improvement are proposing. But there is a widespread perception that in time ICSs will need to become statutory bodies. There is no desire, however, for that to happen quickly – these organisations are still being built in flight.

Is there a pipeline of future ICS leaders?

There are real concerns about that. First, whether there are enough people coming through with experience across different parts of health and social care, given that the ‘purchaser–provider’ split has tended to force people’s careers into one silo or another. And second, given that ICSs are not legal entities, taking on the role of leading one is seen as insecure and risky. Almost all chairs and many (though not all) leads are at the later stages of their career, so were willing (by their own admission) and able to take the risk.

So, what are the challenges that still lie ahead?

Many are outlined above. A key frustration is the slow pace of change, though some argue that the pace is picking up, and once the first steps are taken change can accelerate. There was widespread agreement that if this can be achieved voluntarily it will stick better than if an attempt was made to impose integrated care by legislation. But the acid test of whether this really improve the population’s health and care is yet to come.