What are integrated care systems?
Integrated care systems (ICSs) are a key part of the NHS long-term plan, and are intended to bring about major changes in how health and care services are planned, paid for and delivered. ICSs are partnerships that bring together providers and commissioners of NHS services across a geographical area with local authorities and other local partners, to collectively plan and integrate care to meet the needs of their population.
ICSs are the latest in a long line of initiatives aiming to integrate care across local areas. They have grown out of sustainability and transformation partnerships (STPs), local partnerships formed in 2016 to develop long-term plans for the future of health and care services in their area. Compared to STPs, ICSs are a closer form of collaboration in which NHS organisations and local authorities take on greater responsibility for collectively managing resources and performance and for changing the way care is delivered.
ICSs are part of a fundamental shift in the way the health and care system is organised. Following several decades during which the emphasis was on organisational autonomy and the separation of commissioners and providers, ICSs depend instead on collaboration and a focus on places and local populations as the driving forces for improvement. Despite being effectively mandated by NHS England and NHS Improvement, ICSs and STPs are currently voluntary partnerships as they have no basis in legislation and no formal powers or accountabilities.
Currently ICSs have been established in 18 areas (see Map 1). The rest of England is covered by 24 STPs, all of which have been working to strengthen partnerships so that they can take on the greater roles and responsibilities of an ICS. The NHS long-term plan set an ambition for all areas of England to be covered by an ICS by April 2021. Inevitably, the development of ICSs will take a back seat in the coming months as local and national health and care leaders rightly focus their efforts on responding to the Covid-19 (coronavirus) outbreak. In this explainer, we take stock of how local systems were developing before the outbreak.
Why are integrated care systems needed?
The NHS was set up primarily to provide episodic treatment for acute illness, but it now needs to deliver joined-up support for growing numbers of older people and people living with long-term conditions. Health systems all around the world are having to adapt in response to this changing pattern of need. As a result, the NHS needs to work differently by providing more care in people’s homes and the community, and breaking down barriers between services.
The central aim of ICSs is to integrate care across different organisations and settings, joining up hospital and community-based services, physical and mental health, and health and social care. ICSs are coming together at a time when improvements in life expectancy are stalling and health inequalities are widening. They have the potential to drive improvements in population health by reaching beyond the NHS to involve local authorities and other agencies to tackle the wider determinants of health that drive longer-term health outcomes and inequalities.
Systems, places, neighbourhoods
A key feature of ICSs is the emergence of ‘systems within systems’ to focus on different aspects of their objectives. This means that within the partnership that makes up an ICS, there are also smaller partnerships centred around more local areas and populations. These are important as ICSs tend to cover large geographical areas (typically a population of more than 1 million) so aren’t well suited to designing or delivering changes in services to meet the distinctive needs and characteristics of local populations.
NHS England and NHS Improvement has adopted the terminology used in some systems to describe a three-tiered model.
Map 2 An example of the places and neighbourhoods within an ICS
While this looks neat on paper, arrangements vary widely in practice and there are many exceptions to the population sizes listed above. In some large systems an additional fourth layer of geographical organisation has emerged, for example in North West London, where the ‘places’ are grouped as inner and outer London boroughs.
How the different layers interact and relate to one another is inherently complex. Far from being a traditional hierarchy, these arrangements are more akin to an ecosystem with many connections and interdependencies between the partnerships at different levels. Local systems are taking different approaches to deciding which functions should sit at each level. For example, West Yorkshire and Harrogate ICS has agreed three ‘subsidiarity tests’ that it uses to determine whether something should be led by the wider system or by the local places within it. The challenge is to ensure that the activities of the different groups form part of a coherent, mutually reinforcing approach, rather than becoming a disjointed or duplicative set of initiatives. The King’s Fund is conducting research to understand this in more detail.
How are integrated care systems developing?
There is no blueprint for developing an ICS; so far, their development has been a locally led process with significant differences in the size of systems and the arrangements they have put in place. There is also wide variation in the maturity of partnership-working across these systems. The national NHS bodies have adopted a permissive approach meaning that, in contrast to many previous attempts at NHS reform, the design and implementation of ICSs has been locally led within a broad national framework. This approach leaves some uncertainty around what the end-state of the changes will be, and variation across the country can make these reforms more difficult to understand. However, the advantage of this approach is that it enables systems to build on the strengths of their local leadership and existing relationships.
The systems that are furthest ahead are those that have given priority to strengthening collaborative relationships and trust between partner organisations and their leaders. This has often been achieved by leaders from different organisations spending time together to work through the challenges facing the system and individual organisations, clarifying a shared purpose for working together, and undertaking focused development work with their leadership groups.
ICSs have focused their work on a number of areas, including:
- agreeing the objectives and priorities of the system
- establishing governance to support partnership-working and collective decision-making – systems have built on successive iterations of their governance as the ICS develops
- building capacity and capability to support the work of the system – teams to deliver this work are being resourced by organisations offering people from within their existing teams, or by pooling resources or drawing on transformation funding where it is available
- agreeing system-wide leadership arrangements – all ICSs have an executive lead and are appointing independent non-executive chairs. These roles have no formal authority; they rest on soft power and influence, and require a facilitative and enabling leadership style.
Some ICSs have also begun to support changes within their local systems, for example, by developing joint strategies to address workforce shortages and making it easier for staff to work flexibly across different organisations, and making progress on developing electronic patient records and information-sharing. All ICSs and STPs have been developing local responses to the NHS long-term plan, with the first of these local plans being published early in 2020. Others were set to follow shortly after, but the need to prioritise the response to Covid-19 means their publication has been delayed until later in the year, and some of the planning assumptions may need to be revisited.
ICSs have also been grappling with the question of how best to involve key partners. Although they originated from the NHS, ICSs cannot achieve their ambitions of improving population health without involving colleagues in local government, the voluntary and community sector and others. There is wide variation in the extent of their involvement across different ICSs, and while there is some evidence of progress in terms of the role of local authorities (see below) it remains unclear how voluntary and private sector organisations can be meaningfully involved despite being key delivery partners for many services.
How are ‘places’ developing?
New leadership arrangements and governance structures are being created at ‘place’ level as well as at the level of the ICS to support collaboration and to enable decision-making and accountability to be distributed to the most appropriate level.
The main focus of the work at ‘place’ is to implement new care models. In some areas this builds on the work of the vanguards programme, which developed and tested integrated delivery models described in the NHS five year forward view. Approaches vary widely between different areas, including between ‘places’ within a single ICS. The common feature of these models is that they involve alliances of providers working together to deliver care by agreeing to collaborate rather than compete. The providers involved may include hospitals, community services, mental health services, groups of GPs, social care providers and independent and third sector providers. Some are informal partnerships, while others have more formal arrangements through alliance contracts or through an NHS trust acting as a lead provider and subcontracting services from partners.
In many areas, alliances at ‘place’ level are referred to as integrated care partnerships (ICPs). However, there are variations on this terminology, for example, in the South East London ICS they are referred to as ‘local care partnerships’ (LCPs) and in Greater Manchester as ‘local care organisations’ (LCOs). These different acronyms reflect local preferences rather than any significant differences in the work being done by the partnerships.
How are neighbourhoods developing?
Since 1 July 2019, all but a handful of GP practices in England have come together in around 1,300 geographical primary care networks (PCNs) covering populations of approximately 30–50,000 patients. This was encouraged by a new GP contract that channels money for new staff directly to general practice via the newly formed PCNs.
Much is expected of these new networks. Over time, they will be required to deliver a set of seven national service specifications, provide a wider range of services in primary care, use the skills of a greater range of professionals and work closely with other services in the community through multidisciplinary teams.
They have also been described by NHS England and NHS Improvement as the ‘building blocks’ of ICSs. According to the NHS long-term plan, every ICS must have full engagement with primary care through the named accountable clinical director of each network, and PCNs must be represented on the partnership boards of all ICSs. However, this won’t be as straightforward as giving all network accountable clinical directors a place on their ICS partnership board. Some larger ICSs will have more than 60 networks – and therefore more than 60 accountable clinical directors – meaning that networks will need to work together to organise and represent the voice of PCNs. It is still early days, and it remains to be seen how the relationship between PCNs and ICSs and/or ICPs will develop. In their initial stages, most PCNs have been focused first and foremost on stabilising general practice, leaving less space to focus on building partnerships with wider community-based services or engaging with their ICSs and ICPs.
What does this mean for commissioning?
One of the consequences of these developments is that the commissioner–provider split that has underpinned health policy since the early 1990s is becoming blurred. Commissioners are working hand in hand with local providers to plan care for their populations, and commissioning is becoming more strategic, focusing on the planning and funding of new models of integrated care rather than being based on annual contracting rounds.
Clinical commissioning groups (CCGs) are working more closely with each other at a system level through joint management structures or formal mergers. At the same time, many CCGs are working with local authorities at ‘place’ level to align and integrate commissioning for some services. The NHS long-term plan set out an expectation that systems would streamline commissioning arrangements so that there is ‘typically’ a single CCG for each ICS. There has since been significant consolidation of CCGs in line with this guidance, with further mergers expected over the coming months. However, merging CCGs by default risks undermining local collaborative planning structures, particularly existing arrangements across NHS and local government commissioners. Some systems are therefore pursuing alternative arrangements, such as Greater Manchester where the 10 constituent CCGs are developing closer working arrangements with their co-terminous local authorities at the ‘place’ level (including through joint leadership) while the wider Greater Manchester health and care partnership supports some commissioning activities to be led across the system.
NHS England and NHS Improvement has set out plans to give local systems a greater say in how the specialised commissioning budget is spent in their area (NHS England is currently responsible for directly commissioning some specialised services, such as neonatal services and treatments for rare cancers). New arrangements are being developed to give STPs and ICSs an advisory role in planning specialised services, and local areas can apply to take on greater responsibilities for certain aspects of specialised commissioning. There is currently no single model for this, and proposals are approved on a case-by-case basis.
What does this mean for providers?
At system level, the key role of providers is to work with others to plan the transformation of services and to manage system performance. At place and neighbourhood levels, their role is to collaborate with other providers (including from outside the NHS) to design and deliver more integrated services for local populations.
Increasingly, providers are taking on commissioning-type roles (such as redesigning care pathways and ensuring medicines are used safely and effectively) and some local planning is done collaboratively across the commissioner–provider divide. Where these changes are most advanced, the traditional purchaser–provider split has become significantly blurred, for example, in Croydon (one of six ‘places’ within the South West London STP) a single ‘place-based leader’ has been appointed as chief executive of the main local provider and in a senior leadership role at the CCG, along with several other joint executive appointments. Payment models are also changing, with many examples of providers and commissioners agreeing to move away from activity-based payments for acute services in favour of block or aligned-incentive contracts.
Within ICSs, there is growing evidence of providers working with each other, including through hospital groups and clinical networks. Reasons for this include joining-up care pathways, reconfiguring services across different sites to address issues of quality or sustainability and addressing workforce shortages by sharing staff and co-ordinating efforts to improve recruitment and retention.
Despite these changes, the statutory roles of providers and commissioners remain unchanged. This poses a challenge to local leaders, who are expected to work in the interests of their local system, while remaining formally accountable for the performance of their individual organisations.
What is the role of local government?
The involvement of local government is essential for ICSs to be able to drive meaningful improvements in health and wellbeing. It can bring three key benefits. The first is the opportunity to join up health and social care at all levels in the system, creating better outcomes and a less fragmented experience for patients and users. The second is the potential to improve population health and wellbeing through the NHS and local government acting together to address wider determinants of health such as housing, local planning and education. Finally, the involvement of local government can enhance transparency and accountability through supporting engagement with local communities and providing local democratic oversight.
Collaborating across the NHS and local government is not easy, and requires local leaders (including NHS leaders as well as officers and elected members in local government) to better understand each other’s challenges, to recognise and respect differences in governance, accountabilities, funding and performance regimes, and to find ways to manage these differences.
While the extent of engagement still varies widely, there is evidence that local government is playing a stronger role in ICSs than it did in the early days of STPs. In most cases, local authorities are part of the ICS board and/or other parts of the governance arrangements, and within some ICSs local government representatives are leading programmes and/or offering wider leadership as the ICS lead or independent chair. In some systems, health and wellbeing boards are playing a key role in the ICS governance, and there is also a growing role for overview and scrutiny committees.
Importantly, partnerships between local government and NHS organisations are also developing at the level of ‘place’. This can be a more natural footprint for collaboration, and it is often at this more local level that planning and services can join up most effectively. It will therefore be essential to continue to foster and support these local partnerships as ICSs develop.
What does this mean for oversight and regulation?
Despite the focus on collaboration and system-working in recent years, the primary focus of NHS regulators has continued to be on managing the performance of individual organisations. The interventions and behaviours of the regulators have sometimes made it more difficult for organisations to collaborate. To address this, the Care Quality Commission (CQC) has begun to test approaches to regulating systems, and NHS England and NHS Improvement has created seven joint regional teams bringing together the regulation of commissioners and providers.
It is early days for these new regional teams; their approach and the way they will work with ICSs is still evolving, and there are some emerging signs that this is developing differently in different regions. It is hoped that the new regions will develop new ways of working alongside local systems, supporting them to change and improve services as well as overseeing performance.
In line with these ambitions, NHS England and NHS Improvement has committed to changing its approach to ‘system by default’, meaning that wherever possible it would work with ICSs to identify and address performance issues rather than going directly to individual organisations. This approach remains under development, and further detail on what it will mean in practice is expected in due course (this was expected imminently, but it is likely that this will be put on hold to enable leaders to prioritise the Covid-19 response). As the ‘system by default’ approach is developed further, it will be important to ensure the changes do not simply create an additional regulatory tier, and that it doesn’t lead ICSs to focus exclusively on NHS performance at the expense of wider local priorities.
Recent guidance makes clear that ICSs will be expected to manage system performance. This means organisations within an ICS taking mutual responsibility for each other’s challenges and taking collective steps to address these. This reflects the fact that challenges in individual organisations, such as pressures on A&E departments, are often symptomatic of issues within the wider system. Working in this way would be a significant step for most systems and raises the question of whether ICSs have the capabilities to take on this role and whether they have the resources and levers at their disposal to do so.
Why have some of these changes been controversial?
A number of concerns have been raised in relation to these developments. STPs received widespread criticism in their early stages for developing plans behind closed doors, failing to engage the public and key partners, and proposing unrealistic financial savings. The work of systems has moved on significantly since these early stages; there has been a focus on broadening communication and engagement in the work of STPs and ICSs, and many of the more controversial proposals contained in the 2016 plans have been dropped in recognition that some of their assumptions around financial savings and reductions in hospital capacity were unrealistic.
Concerns have also been raised in relation to the accountability and transparency of ICSs. As they are not statutory bodies, there are no formal requirements around the governance of ICSs, and it is not always clear how decisions have been made. Some systems have taken steps to address these concerns by developing their governance structures, building in local democratic oversight, meeting in public and publishing papers and information.
Controversy has arisen around whether these developments could open the door to privatisation of the NHS. Concerns were most prominent around the development of the integrated care provider contract (previously known as the accountable care organisation contract – terminology that stoked fears of a move to an American-style health system), with campaigners arguing that this could lead to health and care services coming under the control of private companies. Two judicial reviews were brought against NHS England in relation to the contract, but both were dismissed. The NHS long-term plan subsequently set out an expectation that integrated care provider contracts would be held by public statutory providers, and NHS England and NHS Improvement has proposed legislative changes to formalise this. The emergence of stronger public sector partnerships and the erosion of market-based reforms are unlikely to lead to a larger role for private companies in delivering NHS services.
Does the establishment of ICSs require a change in the law?
ICSs are not statutory entities, and there is no specific legislation governing how they operate. Progress to date has been made by local leaders working around the current legal framework, making use of flexibilities such as the ability to form joint committees across organisations. The problem with these workarounds is that they are complex and risk being unstable if partner organisations disagree. There are also concerns about the lack of accountability and transparency of non-statutory arrangements, particularly as ICSs are intended to play an increasingly important role in the planning and prioritisation of a significant amount of public spending.
Legislative changes will be needed sooner rather than later to support progress and to bring the statutory framework into line with changes to local services. However, ICSs are evolving and there is wide variation in their maturity, meaning that any legislation in the short term will need to strike a balance between providing sufficient clarity and creating enabling flexibilities without inhibiting progress by over-specifying structures.
NHS England and NHS Improvement has developed proposals for a limited set of targeted legislative changes to support the development of ICSs. These include proposals to reduce the role of competition and procurement in the NHS, and to allow NHS organisations to work together through new joint committees. The government has since said it is considering these recommendations and will bring forward detailed proposals shortly, followed by draft legislation.
Key challenges in the next stages of these developments include:
- the importance of local leaders investing time and effort in building trust and collaborative relationships, and overcoming competitive behaviours that create barriers to partnership working
- the challenge of making progress while also dealing with immediate financial and operational pressures
- the need to prioritise the development integrated planning and delivery at ‘place’ and ‘neighbourhood’ levels alongside the development of ICSs
- understanding and acting on insights from patients and local communities, developing new methods of ongoing engagement and bringing together dispersed insight and feedback data
- avoiding a narrow focus on the NHS and ensuring full involvement of local government and voluntary and community sector organisations; this is essential if ICSs are to realise the wider prize of improving population health and wellbeing
- the need for national NHS bodies to strike a balance between offering guidance and support while allowing room for locally led change, recognising that there is no single model that will work everywhere
- bringing forward legislative changes that will support organisations to collaborate rather than compete as well as providing greater clarity and transparency, without creating the upheaval of another top-down reorganisation
- continuing to align oversight and regulation more closely behind the work of systems; the evolving role of the regions established by NHS England and NHS Improvement and the development of the ‘system by default’ approach will be key to this.
The scale and complexity of these changes should not be underestimated. They require leaders and staff across the health and care system to work differently, collaborating across organisational boundaries to deliver better health and care. Structural and organisational changes on their own will not deliver these improvements; the focus should be on establishing different ways of working and new models for delivering care, with changes to governance and structures supporting rather than driving the change.
Evidence from previous attempts to integrate care indicates that these changes will take time to deliver results. This means that local and national leaders need to make a long-term commitment to the development of ICSs and avoid the past mistake of moving swiftly to the next reorganisation when desired outcomes are not rapidly achieved.
The experience of the first ICSs underlines the importance of partnerships in local places and neighbourhoods; there is growing recognition that most of the work to design and deliver more integrated services needs to be led by these local partnerships. As other areas work towards becoming ICSs, they will need to prioritise the development of PCNs and place-based partnerships if they are to achieve their ambitions.
The development of ICSs, particularly the governance and structures associated with them, will understandably take a back seat while the system focuses on responding to the Covid-19 outbreak. Inevitably, the Covid-19 outbreak and the health and care system’s response to it will alter the context in which ICSs operate, and may also impact on relationships between local partners. Some of these changes may help the work of ICSs; there are already examples of rapid progress being made in transforming care models, for example, through expanding access to digital services and implementing rapid response community-based services. The outcomes and learning from this experience may shape the next stages in the development of place-based care.
Where does the Health and Wellbeing Board fit in this structure?
Where should Healthwatch be positioned to best inform and influence the ICS?
These documents are really helpful and they assist in clarifying the policy of integration in a practical user friendly way. After many years in practice I am finally seeing something that actually might work.
This article is a comprehensive analysis of the complexity of health management in England, It is really important that we keep the "main thing, the main thing" (to misquote Steven Covey) i.e for all of us involved to focus on positive citizen experience and achieving the very best health and care outcomes.