The Scalpel's Blog


System working in an uncertain world

What, exactly, is an integrated care system? Well, it’s unclear, writes Kacey Cogle, policy advisor at NHS Providers.

On the NHS England website, integrated care systems (ICSs) are not clearly defined, referring to STPs (sustainability and transformation partnerships), the predecessor of ICSs, in the first few lines without clarity on the differences between the two. So it is unsurprising that there is some confusion within STPs over what they need to do to become an ICS.  

Definitions notwithstanding, all of England will be covered by ICSs by April 2021, under the commitments set out in the long-term plan. This means that no matter where existing local systems are on their journey to integration, they’ve now just two years to get there.

It’s a tall order, especially for areas that have only recently started to work in partnership. These areas will have the longest journey ahead of them, especially considering the variability that exists between local partners. Some of the most advanced ICSs have been working on their transformation for decades, having had considerable time to develop critical relationships. In other areas, those relationships can be quite fractured or need time to develop. A lack of funding and capital investment, workforce challenges and organisational and financial performance are all additional factors that could hamper the move to collaboration or distract local leaders from the time and personal commitment they would otherwise give to system working.

The lack of a statutory underpinning for ICSs is seen by many as the next most obvious challenge. While ICSs are a welcome move to local collaboration, they don’t have a basis in law and derive their legitimacy from their component organisations: usually providers, CCGs and local authorities. It is therefore unclear how ICSs will be held to account for their decisions and how they will hold their partners to account for the system goals and performance measures described in the plan. The strength of trusts’ autonomous unitary boards, with non-executive directors forming a majority, is that they can practice proper corporate governance, manage risk and be subject to scrutiny and challenge.

However, flexibility in existing legislation allows for ICSs and other collaborative partnerships between providers, and between providers, commissioners and local authorities to form. We know that many providers and their partners have developed governance structures that can support collaboration and integrated services in this environment while managing risk.

In fact, ICSs and the move to system working may well mean an enlarged role for providers at a system level. The plan states that commissioners and providers will make shared decisions around population health management, with providers required to contribute to system wide goals on population health. The new ICP contract would offer a way for trusts to influence population health, as a single contract through which a number of services (primary, community, acute and mental health care) could be commissioned from a lead provider organisation, responsible for delivering integration of services. This approach is one of many partnership arrangements that are available to STPs and ICSs to achieve the commitments in the long term plan but there remain some unanswered questions around the uptake of the ICP contract and whether it is fit for purpose.  

The ultimate uncertainty though, is arguably the broader environment in which the plan was published. Given the key roles that public health and social care play in effective health and care systems, it is unfortunate that the long term plan was published ahead of the expected green papers. Securing sufficient funding for public health, social care, capital spending, education and training is fundamental to the successful delivery of the plan. Indeed, the lack of clarity around these issues has created a very uncertain environment in which systems are being asked to plan and transform.

But it’s not all doom and gloom. ICSs are already flourishing, providing joined up, patient-centred integrated care. Developing systems can be supported to overcome these challenges by more advanced “partners” offering tailored support. Any pathway to ICS ‘status’ will need to incorporate this supportive approach. NHS Providers – working with the Local Government Association, NHS Confederation, and NHS Clinical Commissioners – have developed a Peer Support programme of bespoke support to local system leaders, using senior, experienced peers who work within the NHS and social care organisations or have very recent experience of leading and supporting local system working in their development. It will take approaches like this as part of a wider programme of support, to identify, and then overcome, the challenges ahead.


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