If COVID-19 has strengthened the understanding of health inequalities within the NHS, it is ICSs that national leaders will rely upon to bring different parts of the system together to address them.
System working has accelerated during the pandemic, bringing leaders together with the shared aims of supporting their communities through COVID-19, and keeping services on a sustainable footing in spite of restrictions and operational pressures. The health and care bill will put ICSs on a statutory footing with legal responsibilities to proactively reduce health inequalities and formalise relationships across a broad coalition of partners. It therefore offers a chance to solidify this focus on reducing inequalities and formalise structures being put in place to ensure accountabilities are clear.
We are now beginning to see health inequalities fully embedded alongside other operational priorities within documents setting out how NHS organisations must use resources, plan services, and deliver care for their local populations. There remain questions about how, in practice, ICS leaders will fulfil their duties to address health inequalities alongside their responsibilities in respect of managing budgets and ensuring the sustainability of services.
We are now beginning to see health inequalities fully embedded alongside other operational priorities within documents setting out how NHS organisations must use resources, plan services, and deliver care for their local populations.
NHS England and NHS Improvement’s Integrating care paper
NHS England and NHS Improvement’s Integrating Care paper (2020) outlined the intention to build relationships between the NHS and local authorities, and builds on The NHS Long term plan vision of joined up care centred around people’s needs. This includes the observation that collaboration between partners in a place across health, care services, public health, and voluntary sector can overcome competing objectives and separate funding flows to help address health inequalities. The paper sets out the intention for ICS leaders to be empowered to distribute resources in line with targeted local investment priorities on health inequalities, as well as meeting their obligations to other national spending rules such as the mental health investment standard.
The paper also describes how ICSs will serve four fundamental purposes, which include improving population health and healthcare, and tackling unequal outcomes and access. Tackling inequalities is also a prime focus for provider collaboratives and place-based partnerships, which have a crucial role in delivering ICSs’ local plans to improve the health of their populations. It will be crucial for ICSs to involve local people and communities, particularly those affected by inequalities, in the ICS decision making and service design process.
The emphasis on providers and place as key to integrating care, and the acknowledgement of the need to collaborate on different footprints to achieve different objectives, provided a clear statement of the direction of travel for integrated care systems. However, it also raised important questions about the complexity of the landscape and the need for clear and effective guidance on governance and accountabilities.
Collaboration between partners in a place across health, care services, public health, and voluntary sector can overcome competing objectives and separate funding flows to help address health inequalities.
Health and care white paper
The government’s white paper laying the foundation for the health and care bill, Integration and innovation: working together to improve health and social care for all (Department of Health and Social Care, 2021), gave a stronger indication of forthcoming legislative proposals for integrated care systems. It positioned the Bill as the primary enabler of progress on health inequalities, stating: "we need the right legislative framework to support the recovery by improving outcomes, reducing health inequalities and making best use of limited resources".
Where Integrating care set out two potential options for the future of ICSs, the white paper cemented the government’s intention to establish them as statutory bodies with a swathe of responsibilities including identifying and addressing population health needs, planning services, allocating budgets, and a duty to meet system financial objectives and deliver financial balance.
The paper also introduced the concept of a statutory 'ICS NHS body' (described in the Bill as the integrated care board) and a separate ICS health and care partnership, which would comprise of broader system partners to develop a plan that addresses the wider health, public health and social care needs of a system.
The ICS design framework
The ICS design framework (NHS England and NHS Improvement, 2021) builds on the vision outlined in Integrating care and the white paper, and sets out an operating model for ICSs from April 2022 following the enactment of the Health and Care Bill, which will put ICSs on a statutory footing.
The paper sets out how the integrated care board (ICB) will take on the commissioning functions of clinical commissioning groups (CCGs) and be accountable for planning to meet population health needs, allocating resources and overseeing delivery of services. Its board will be comprised of a chair, a chief executive, non-executive and executive directors and a minimum of three partner organisations representing trusts, primary care and local authorities. The integrated care partnership (ICP) will then bring together wider partners across health and care to align purpose and ambitions, improve the health and wellbeing of their populations, and influence the wider determinants of health.
This governance structure raises questions about how an emphasis on health inequalities will operate in practice. Trusts will be expected to work alongside system partners at place level to tailor their services to local needs and contribute to population health improvement as anchor organisations, and they will increasingly be judged on their contribution to the objectives of the ICS as well as their existing duties. Alongside this, the ICB will have duties in respect of population health and health inequalities, but it is the ICP which brings together the wider partners necessary to develop a truly holistic approach to addressing inequality.
Systems will need to ensure all parties agree to, and are fully invested in, their priorities and ambitions. ICBs will need to balance their regard for the ICP’s strategy and ambitions to tackle health inequalities with their other responsibilities, such as operational performance and financial control.
Health and Care Bill
The government’s Health and Care Bill (July 2021) focuses on developing and formalising system working, and putting ICSs on a statutory footing, building on proposals put forward by NHS England and NHS Improvement in Integrating care. In seeking to remove barriers to collaboration and remove the promotion of competition as a means to achieving good, sustainable healthcare services, the Bill offers an opportunity for the health and care system to work more closely, and benefit from the reduction in friction between different parts of the system.
To support the ambition for ICSs to improve population health outcomes and tackling inequalities, ICBs will have a statutory duty to reduce health inequalities. The Bill sets out that each ICB 'must, in the exercise of its functions, have regard to the need to a) reduce inequalities between patients with respect to their ability to access health services, and b) reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services'.
A new statutory duty to co-operate will also be fundamental to establishing the ICS as being jointly responsible for reducing health inequalities. The bill introduces a power for the secretary of state to make guidance on how the duty imposed on NHS bodies to cooperate with each other is discharged. It also imposes duties on NHS bodies and local authorities to cooperate with one another to advance the health and welfare of the people of England. This duty further strengthens a requirement for health and care partners to work together to improve population health, and although it does not explicitly refer to health inequalities, this is one of the primary goals around which system partners have, and continue to, convene. The practical implications of this duty are yet to be set out, and it remains unclear what cooperation between local authorities and the NHS might look like in practice given their vastly different funding flows and lines of accountability.
To support the ambition for ICSs to improve population health outcomes and tackling inequalities, ICBs will have a statutory duty to reduce health inequalities.
Opportunities and challenges
A significant challenge for trusts will be to navigate the changing landscape of system working, which will establish new and potentially complex accountabilities. Reducing health inequalities will require system partners to collaborate, and improvements will take time to be realised. The ICP will play a central role at system level in tackling health inequalities, as it will bring together the full range of partners, including local authorities and, potentially, voluntary and community organisations. A strong understanding of the inequalities endured by local communities, and the services they need to address them, will also be crucial at place level. Questions remain about how work to understand and reduce health inequalities at different levels of the system will interact and achieve the right outcomes. Access to timely, accurate and complete granular data is an imperative in ICS’ capability to surface health inequalities and to set in motion quality improvement actions to address them.
Alongside this, the ICB will have its own statutory duty to reduce health inequalities in relation to patients’ access to services and outcomes achieved for them. This offers a clear mandate for the NHS, through integrated care systems, to embed health inequalities improvement into the way it plans and delivers services. Again, there will be a need for a strong relationship and clear communication between the role of the ICP and that of the ICB in tackling inequalities - where the ICB works to improve inequalities in access and outcomes in NHS services, the ICP will play a role across the wider determinants, pathways between NHS and other services such as social care and contribute a broader understanding of the breadth and complexity of inequalities people face.
The role of wider partners, such as voluntary organisations, in improving access to health and care services and reducing health inequalities is also becoming increasingly recognised. For example, in Bradford and Craven, six trusts used horizontal integration to strengthen a focus on wider inequalities and population health, and vertical integration with primary care and the voluntary sector to improve continuity of care and improve outcomes. The collaborative put in place governance arrangements to support this work, rather than the other way round, and ensured the involvement of the voluntary and social enterprise sector in decision-making.
Reducing health inequalities will require system partners to collaborate, and improvements will take time to be realised.
The ICS model offers a new opportunity for trusts to contribute to a wider partnership, working towards a shared goal. But ICSs remain at different maturity levels when it comes to addressing health inequalities within their footprints. The challenge of determining the right scope and resource required to deliver changes amid the backdrop of continued operational pressures should also not be underestimated.
The acceleration of system working offers an opportunity for trusts and wider system partners to address the wider determinants of health and tackle health inequalities. There is increasing recognition that improving people’s health goes beyond healthcare, but that as an anchor in communities, trusts can also offer a gateway to people receiving support for other services as well as being a healthy employer. A statutory duty upon integrated care systems to reduce inequalities may strengthen the argument for interventions to be funded and supported, leaving trusts with headroom to respond proactively to the needs of their patients. However, this will rely on ICSs having a realistic task themselves. There is a risk that, if shorter-term financial and operational pressures dominate ICBs’ attention, that a focus on health inequalities could be lost, while valuable partnerships could be undermined in being drawn into transactional conversations about the distribution of scarce resources.
The forthcoming comprehensive spending review will set the resource available to fund the NHS’s recovery from the pandemic. Trust leaders are concerned that the settlement will be tight, and there remains a need for national leaders to consider how the development of policies to support system working will enable systems to prioritise tackling health inequalities, embedding this into their approach to managing the immediate operational pressures rather than introducing unhelpful trade-offs.