How are health systems managing the transition to formal integrated care systems? Mark Gould talks to Anne Crofts to discuss the challenges of organising and integrating a vast number of large and complex organisations.
Planning guidance published in January 2020 started the countdown for all systems in the NHS in England to become part of an Integrated Care System, or ICS, by April 2021. The role of the ICS is twofold and will involve coordination of myriad partner organisations to achieve broad system transformation and collective management. To fulfil these roles, each ICS must have the capacity for population health management, service redesign, workforce transformation and digitisation.
Governance and leadership
Each of the 42 ICS footprints in England is now appointing leaders and developing governance arrangements that include a partnership board with NHS, local government and other partners to enable collective responsibility and decision-making. However, as highlighted in the recent NAO Report on the NHS (5 February), there are significant ongoing challenges. Anne Crofts, partner at DACB and expert in commercial health, says: “These include staff shortages, the financial deficits in Trusts and challenges within STPs to maintain and develop the current assets and infrastructure.”
The report highlights the dangers of the ICS model being a “coalition of the willing”, relying on the goodwill of participants in the absence of changes to the current legislative framework.
The ICS system will also agree a sustainable model for resourcing collective functions or activities, and ways of working with respect to financial governance and collaboration.
Will Cleary-Gray is the chief operating officer of South Yorkshire and Bassetlaw ICS, one of the first of the new systems. Luckily, he says the ICS is already following a “historical footprint” based on how patients access clinical services in the area, with district general hospitals forming a natural grouping around the tertiary centre in Sheffield. “Over 90% of health and care needs for 1.5m people in South Yorkshire and Bassetlaw is delivered within that boundary,” he says.
Cross departmental agreement
Cleary-Gray says that on social care issues, all six local authorities in the patch work separately on most issues relating to health and care.
“This has meant conversations which are joint between Health and Care at a system level are more limited to a few priorities that they collectively want to work on with the NHS.
“Keeping people out of hospital and upfront prevention requires closer working together with the NHS and Local Authorities but the focus of this is local.”
Cleary-Gray says that part of the challenge is that the concept of an ICS came from NHS England and NHS Improvement. “What didn’t happen was a cross-departmental agreement to come together.”
Local accountability
Cleary-Gray does not feel ICS leaders need more legal clout, but says organisations within ICS need more clarity to give them the confidence to make changes.
“A good example would be commissioners who are being asked to make sure they have leadership capacity across the whole of South Yorkshire, but also retain accountabilities locally – they would view that as spreading themselves very thinly.”
The NHS Confederation agrees that ICS need more freedoms. It says the regulatory relationship between NHS England, NHS Improvement and ICS needs to be reframed so that ICS plans set the agenda for conversations about how and where systems will make a difference.
“Local leaders need the discretion to tackle the problems faced in their local communities without being boxed in with detailed prescription and limited flexibility over the multiple separate transformation funding streams,” the NHS confederation said in a statement.
Public sector view
Tim Goodson, chief officer for Dorset CCG and the lead for Our Dorset ICS, says the ICS is now well into the implementation phase. Across Dorset, he says there are single mental health and community teams, joining up of IT systems and a single care record.
Integration has been helped by Dorset already having a single Clinical Commissioning Group (CCG), and recent local government changes where nine councils merged into two unitary authorities. Goodson says they are keen to work with the NHS on the wider determinants of health and wellbeing so they can develop a “public sector view on trying to improve health, rather than just an NHS clinical view.”
The Dorset ICS decided against creating a separate ICS management team. Goodson says: “We felt people might think the ICS team could come up with all the answers and solutions, which would be unrealistic.
“We allocated lead responsibilities to our existing team. Our acute chief executives chair our urgent and emergency care and planned care boards, one of our directors chairs our digital board, the chair of the CCG chairs the workforce board. This makes it our business to own and we champion it.”
Framework for challenges
He cautions that the move to ICS does not make challenges go away. “What it does is set a framework for how you deal with these challenges together, so you are not pitching one organisation against another.”
Goodson says the integration agenda has faced accusations that the NHS was about to be remodelled in the style of a US private care organisation.
“In reality, it’s the exact opposite – it’s all about joining up the NHS, public sector, voluntary and charitable organisations. There has been no privatisation agenda at all.”
Integration, he adds, has had to work around legislation introduced in 2012 by then health secretary Andrew Lansley. “Effectively the Lansley reforms still point to competition and the commissioner/ provider split, and that has to be tackled.”
Crofts points out that in September 2019, NHSE&I outlined proposed amendments to the legislative framework to enable greater collaboration and integrated working between providers and commissioners. “This includes, for example, the creation of joint committees, which would facilitate integrated decision-making, and lessening the impact of competition law on some mergers,” she says. She adds, however, that to date, the Lansley reforms remain essentially intact, and continue to present a challenge to the integrated governance and accountability structures of emerging STPs and ICSs.
