Integrated care systems (ICSs) have been proposed as the future model for the health and care system in England. Their development represents a fundamental and far-reaching change in how the NHS works across different services and with external partners.
ICSs’ development has been locally led and there is no national blueprint. We carried out interviews in eight of the ‘first wave’ ICSs to understand how they are developing and to identify lessons for local systems and national policy-makers.
The systems vary widely in their size and complexity. Larger ICSs are working to improve health and care through neighbourhoods and places as well as across whole systems, emphasising the principle of subsidiarity.
Most ICSs are making progress in developing their capabilities to work as systems, and organisations are working more collaboratively to manage finances and performance in a way that was not happening previously.
There are some early signs of progress in delivering service changes, particularly in relation to strengthening primary care, developing integrated care teams and reviewing how specialist services are delivered. It is early days, and more time is needed to embed these changes and determine their impact.
The challenge now is to build on the foundations that have been laid by removing barriers and providing time and support to ICS leaders to take their work to the next stage of development. As this happens, the understandable desire to see change happen quickly needs to be married with realism about the scale and complexity of what is being attempted.
Where once the primary purpose of the health and care system was to provide episodic treatment for acute illness, it now needs to deliver joined-up support for growing numbers of older people and people living with long-term conditions. To meet this challenge, the NHS and its partners must break down barriers between services and give greater priority to promoting population health and wellbeing.
This aim is being pursued through sustainability and transformation partnerships (STPs) and the evolution of some STPs into ICSs. These ‘place-based’ partnerships will be given more control over local funding and services in the hope that they can make better use of resources and improve the health and wellbeing of their populations. ICSs and STPs have no basis in legislation, and rest on the willingness and commitment of organisations and leaders to work collaboratively.
In June 2017, NHS England announced ten areas to develop the first ICSs. A further four were selected in May 2018, and others will follow. They are expected to become increasingly important in planning services and managing resources in the future.
The aim of this study was to understand how ICSs are developing and identify emerging lessons for local systems and national policy-makers. We conducted interviews with 72 NHS and local government leaders and other stakeholders to examine progress in eight of the first ICSs.
Bedfordshire , Luton and Milton Keynes ICS
Berkshire West ICS
Lancashire and South Cumbria ICS
Nottingham and Nottinghamshire ICS
South Yorkshire and Bassetlaw ICS
Our research identified activity at three main levels; neighbourhoods, places and systems. There was broad agreement that all are important in making progress on integration. Current ICSs vary widely in their size and complexity, and therefore in the level at which they are operating (see Figure 1). In future, they are likely to evolve to take on system-level functions, such as strategic planning, aligning commissioning and providing overall system leadership.
Figure 1: Variations in the level at which ICSs are operating
Early changes in service models include work to strengthen and integrate primary care and community services and to improve information sharing. This work is commonly focused at the place or neighborhood level, and often builds on pre-existing models. Some have undertaken work to review how specialist services are delivered.
ICSs have also focused on establishing the governance needed to work as systems. This has been an iterative process and arrangements will continue to evolve. System-wide governance must work alongside the accountabilities of statutory organisations, and this can create tensions between system objectives and organisational accountabilities.
Leadership in ICSs requires a collective and distributed approach. We found evidence that individual leaders are spending more time looking outside of their own organisations to lead across systems, and that this has involved a shift in their perspectives and leadership styles.
The ICSs that are furthest ahead are those that were already working as systems and have given priority to strengthening collaborative relationships and trust between partner organisations and their leaders. This has often been achieved by establishing common cause, spending time together, and undertaking focused development work with their leadership groups. Some ICSs have found it more difficult than others to establish common cause among partner organisations.
Involving key partners
We found a number of examples of patient and public engagement by ICSs, but much greater attention will be needed to bring this to the fore of their work. Similarly, there is limited evidence of engagement with the voluntary and community sector to date. More positive progress has been made regarding the involvement of local authorities, with benefits including a stronger connection with local communities, closer working across health and social care, and opportunities to act on the wider determinants of health. Clinical leadership has been central to progress in some ICSs, particularly in implementing service change, but engagement of frontline staff is not yet widespread.
The role of national NHS bodies
The national ICS programme, which has taken a permissive and supportive approach, is generally viewed positively and local systems report that it has helped them to make progress. ICSs were more critical of the approach of regional teams, who have been slow to align their approach with local systems. In spite of promises that ICS status would mean an improved ‘one-stop shop’ regulatory relationship with NHS England and NHS Improvement, the experience on the ground remains largely unchanged, with a focus on organisational performance and accountabilities and conflicting messages from the two bodies. This is a significant barrier to progress and needs to be addressed.
ICSs have only been in operation for a year, but there are encouraging signs of progress. The evidence reported here shows that partner organisations and their leaders are working more collaboratively to manage performance and finances across a system in a way that was not happening previously. Evidence of tangible improvements in services and outcomes is limited to date, but this is to be expected given the brief time ICSs have been in existence. This must be a key priority for all ICSs going forward. We found broad consensus that the ICS model has real potential to bring about improvements in health and care, and to place services on a sustainable footing.
|• Collaborative relationships • Shared vision and purpose • System leadership • Clinical leadership and engagement • Partnerships with local authorities • A meaningful local identity • Established models of integrated working • Stability of local finances and performance • Funding to support transformation • A permissive and supportive national programme
|• The legislative context does not support system working • A legacy of competitive behaviours • Regulation and oversight is not aligned behind ICSs • Frequently changing language and the lack of a clear narrative • Leaders face competing demands • Funding pressures can both help and hinder progress
Recommendations for local systems
Invest in building collaborative relationships at all levels of the system – this can only be done locally and takes time and commitment.
Promote and value system leadership – ICS leadership should be developed with a continuing emphasis on collective and distributed leadership, ensuring leaders have dedicated time to fulfil their roles.
Integrate at different levels of the system, building up from places and neighbourhoods – In line with the principle of subsidiarity, ICSs should set the overall vision, provide leadership across the system and undertake functions that are best performed at scale.
Draw on the skills and leadership of frontline staff – staff should be front and centre of plans to redesign services, with clinical leadership at the fore.
Build governance in an evolutionary way to support delivery – this should be iterative and locally led, ensuring that it does not conflict with accountabilities of statutory organisations.
Develop system-wide capabilities to gather, share and act on public insights – ICSs must take active steps to listen to and work with the public on an ongoing basis, and to bring together dispersed insight and feedback data from across the system.
Develop active strategies to facilitate wider adoption of new care models – this requires an active approach centred around peer-to-peer learning and networks.
Build robust evaluation into the ICS programme that supports learning and improvement and measures progress – metrics should reflect the breadth of ICSs’ priorities, and recognise that much of the impact will emerge in the long term.
Look beyond the health and care system to improve population health – this requires deeper local authority involvement and closer working with the voluntary and community sector, independent sector organisations and communities (see Figure 2).
Figure 2: What does it mean to move from integrated care to population health systems?
Recommendations for national leaders
Back locally led change, while also offering central guidance and support – working with local leaders, national bodies should further develop the support programme for current and future ICSs to facilitate peer-to-peer support and the spread of best practice.
Clarify the future size of ICSs without destabilising existing systems – smaller ICSs will need to find ways to manage system-level functions, but any move to bring them together should be locally led and rigorously tested to avoid destabilising nascent relationships.
Make a long term national commitment to ICSs backed by dedicated funding – ICSs must be allowed time to develop. The NHS 10-year plan should set out a route map for areas to progress from STPs to ICSs, earmark funding to support their development, and communicate simply and clearly why ICSs are needed.
Make population health the centrepiece of plans to transform services – the 10-year plan should set realistic and measurable objectives for improving population health, and ICSs should be held to account for delivering these locally.
Reform regulation to align with local systems – regulators should measure and support the ability of local systems to meet the needs of their populations. This requires a shift in mindsets and behaviours among those working in regulators.
Work with local leaders to clarify how ICSs fit into the regional architecture – the starting point should be to clarify the functions of the seven regions and how these relate to ICSs’ functions, ensuring that this does not create an additional tier of bureaucracy.
Model collective leadership and create a supportive regulatory environment – national and regional leaders in NHS England and Improvement should demonstrate a commitment to collective, compassionate leadership, creating a proportionate approach to regulation and enabling local leaders to develop their own improvement capabilities.
Redesign the financial architecture to incentivise integration – current financial rules must be changed to support the aspiration to deliver more integrated care.
Bring forward proposals for legislative change drawing on the experience of leaders within the health and care system – legislative changes will be needed to support the development of ICSs. Leaders should identify amendments that could support immediate progress, while also formulating proposals for more significant changes in the longer term.