Six months in, the NHS’s new integrated care systems (ICSs) are already the subject of an independent review led by Patricia Hewitt. It is still early days for ICSs. Local leaders are developing strategies for the next five years and making sense of their new responsibilities. They are grappling with big NHS workforce shortages, exhausted staff and a lack of capacity in community services – especially social care. ICSs also face continued NHS industrial action, a growing elective care backlog and ambulance delays that are placing patient safety at risk. November’s Autumn Statement provided some short-term financial relief for health and care but is unlikely to be enough to return services to pre-pandemic levels of care.
Government has asked Patricia Hewitt to make recommendations for how the ‘oversight and governance’ of ICSs can ‘best enable them to succeed’. So where should she focus? There are unanswered questions facing ICSs in at least four areas: balancing priorities, clarifying accountabilities, measuring progress, and ensuring broader policy supports success.
Identifying the core priorities remains challenging
On the face of it, the ask of ICSs is clear. Policymakers have set four purposes for an ICS: improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and support broader social and economic development. But these aims are broad and some – like on social and economic development – are relatively new territory for the NHS and only loosely defined in policy documents. Expectations for progress on these broader objectives have not been set.
Identifying the core priorities for ICSs remains challenging. The slimmer set of national objectives in this year’s NHS planning guidance was a step in the right direction, but other (potentially competing) ‘asks’ are peppered across different policy documents and further plans are yet to come. Without more clarity, higher profile measures – those focused on hospital performance or discharges, for example – are likely to dominate debate. In clarifying priorities and reducing the list of national targets, Hewitt will need to consider how to strike the right balance between national and local, and short and longer term objectives.
System leaders are grappling with opaque lines of accountability
The 2022 Act sought to define roles and responsibilities in the new NHS structure, but the system is complex. Integrated care systems are made up of two parts: integrated care boards and integrated care partnerships. These two bodies operate alongside nascent, non-statutory provider collaboratives, pre-existing Health and Wellbeing Boards, evolving place-based partnerships, local political accountability and changing regulatory structures. For providers, organisational sovereignty remains. Clarifying accountabilities will be key if – as a result of the review – local leaders are to be made ‘more accountable’ for performance and spending. Doing this in a way that avoids yet more structural changes for the NHS is critical.
System oversight – the devil is in the detail
Details of how ICSs will be assessed and measured are still unclear. CQC and NHS England will both play a role, but the future of the proposed outcomes framework for the ‘place’ level of the system is unknown. There are no easy options: ICSs are responsible for the whole health and care system, and the impact of partnerships is hard to measure. ICSs have broad aims, involve multiple organisations and interventions, and their intended outcomes (reducing health inequalities, for example) are shaped by a host of other factors.
Policymakers need to be clear on the aims and purpose of measurement. Is it to judge ICS performance, support local systems to improve, provide information for the public on quality of care, or some combination? Each of these aims requires a different approach, but the focus of the various elements of ICS assessment isn’t immediately obvious. Policymakers must avoid simply layering new measurement approaches for ICSs on top of the various other frameworks and targets that already exist, without thinking how they all fit together. They should also avoid the temptation of simplistic comparisons between areas and set realistic expectations for systems that take into account their very different starting points.
If it’s true that what gets measured gets done, any new approach needs to incentivise action on longer term goals – for instance, on reducing health inequalities – alongside immediate priorities. In the past, the importance of broader ambitions often diminished as the financial backdrop for the NHS worsened and there is a clear danger of history repeating itself.
Broader political decisions risk holding ICSs back
Much time will be dedicated to clarifying the aims, accountabilities and oversight of ICSs, but policymakers will also need to focus on how partners within ICSs work together in practice. ‘Softer’ factors – like trust, culture, and communication – will shape ICS progress. And ICSs will need support from national policymakers to develop the skills and capabilities needed to improve services – for example in better using data and digital technology to improve care.
Ultimately, for ICSs to succeed, broader policy changes will also be needed – including adequate funding for local government and frontline NHS services, sufficient capital investment needed for new buildings, technology, IT, and cross-government action to tackle social and economic drivers of health. These political choices sit beyond the control of ICSs or the Hewitt review. With or without them, the Hewitt review can still make a positive contribution by leaving ICSs with a stronger national steer on their priorities and how they will be measured.
