Diversity of approach
One of the benefits of the national policy focus on system working is that it has allowed for the 'bottom up' development of local plans, particularly in those areas with a history of strong partnership working. There is also considerable diversity across the size of ICSs (in terms of geography and population) and perhaps unsurprisingly, the drivers for change are different in different STP/ICS areas. For example, two of the fourteen ICSs are pursuing a devolution approach; three STPs in the north east are collaborating and seeking to merge under shared leadership with a view to creating a strategic commissioning footprint at scale across a largely rural geography; in contrast smaller ICS footprints, such as Frimley, often focus largely on place-based vertical integration.
Importantly most, if not all, footprints seem to be focusing on breaking down their STP/ICS wide 'umbrella' into smaller, place or neighbourhood based sub systems where the majority of frontline change to integrate care for patients takes place. However the 'boundaries' of these smaller footprints vary – either based on health and wellbeing boards, local authority boundaries or another sense of place based identity’. Some footprints are also using horizontal integration at scale as a vehicle for change within the STP banner particularly where there is support, or a need for, CCG and/or provider consolidation. Equally, there are some systems where the local pressures are so great that it is difficult to see much progress in moving away from traditional, institutionally focused models of care.
One of the benefits of the national policy focus on system working is that it has allowed for the 'bottom up' development of local plans, particularly in those areas with a history of strong partnership working.
While this degree of diversity of approach is not necessarily negative, it gives rise to interesting (and largely undebated) policy questions about how much diversity we wish to tolerate as a national system, and indeed which models will endure and stay the course.
Emerging, common characteristics of system working
Despite considerable diversity in the models, and the drivers for change, within different STPs and ICSs, some helpful, common characteristics are emerging in those systems which are making progress.
The role of the STP or ICS
For those involved in a more evolved ICS, the system infrastructure is a developing means to maximise collective resources in support of a more ambitious approach to population health management, prevention and integration, to support system performance management and to act as an interlocutor with the emerging NHS England/NHS Improvement regional structure. NHS England and The Kings Fund’s (2018) work with the ICSs is proving helpful in codifying their approaches.
However many trusts, and partners, involved in STPs which are progressing more slowly seem to see the STP as a convener to corral a shared vision and priorities for the wider population (but perhaps as little more). Increasingly, trusts within partnerships across the spectrum tell us that their partnership has moved away from the language of 'the STP' to a locally developed 'brand' which is more meaningful for the public and often for local authority colleagues.
However many trusts, and partners, involved in STPs which are progressing more slowly seem to see the STP as a convener to corral a shared vision and priorities for the wider population (but perhaps as little more).
The blurring of the commissioner/provider split:
The commissioner/provider split requires a political decision (and parliamentary time) to reform. However the recent, rapid consolidation of CCGs (either via mergers or through new collaborative arrangements to share executive teams) supports a move towards enabling CCGs to develop into a more strategic commissioning function.
Work is also underway in a number of systems to consider what activities providers could take on from CCGs within new forms of integrated care partnership (ICP) or integrated care organisation (ICO). Approaches range from collaborative approaches in which CCG and provider colleagues both share expertise to inform new service specifications to an increase in alliance contracts across local provider partners, to the development of more innovative open book and risk share arrangements between providers and CCGs.
Most of the existing financial framework still encourages a focus on individual organisational performance within a single year however a reset is due to take place in time for 2019/20. We believe that the new framework must provide trusts with a realistic and achievable ask. In doing so it should directly support system working (and provide a route out of central control) for those areas ready to adopt this approach. This could involve more clarity on local variation and autonomy, and a clear definition of the roles and responsibilities of NHS Improvement, NHS England and the regional teams.
We believe that the new framework must provide trusts with a realistic and achievable ask. In doing so it should directly support system working (and provide a route out of central control) for those areas ready to adopt this approach.
New and integrated care models:
Different systems are trying different approaches to integrate care. But, drawing on the experience of the new care model vanguards, there is a growing and very interesting focus on the development of:
- primary care networks or community hubs and ICPs which focus on populations of circa 30-50,000 at a neighbourhood level
- ICPs and a smaller group of systems developing ICOs more likely to focus at the level of 'place' i.e. for populations of 250-50,000.
In each model, partners strive to:
- bring together primary care, community care, social care, community mental health services and "acute hospital outreach services" (e.g. physiotherapy) into a single integrated service
- seek to use 'whole population health' management techniques
- often invest in a single care record which aims to combine GP, social care, acute, community provider and mental health community team patient records. This can act as a tool to risk stratify the population:
- proactively supporting patients to manage their own health and wellbeing more effectively
- identifying those most at risk of needing emergency care and seeking to avoid unnecessary hospital admissions
- create a single, integrated multi disciplinary team composed of a variety of different 'existing' healthcare professionals and often including 'new style' care co-ordinators or navigators. This team will:
- seek to ensure patients receive a single joined up diagnosis covering physical and mental health and social wellbeing
- provide a single service to meet these needs, integrating previously separate and disparate services from different organisations
- join up the different elements of care for the patient, with a particular emphasis on ensuring the service is patient focussed and minimises the number of interactions with different health and care professionals
- act as the first and main point of contact / single point of access for as many care services as possible
- act as a navigator of a range of services including third sector and socially prescribed services
- work out how to make best use of existing NHS estate
In each model, partners strive to bring together primary care, community care, social care, community mental health services and "acute hospital outreach services" (e.g. physiotherapy) into a single integrated service.
Governance
Our sense is that governance is rising up the agenda for all systems, including those which are most advanced and based on robust, constructive working relationships. Although it is clear that the current frameworks offer a number of approaches to pursue collaborative working (on a wide spectrum from merger to partnership arrangements), system governance requires a different approach to identifying and managing risk as boards seek to balance organisational level risks with those at the system level. Several trusts have commented that system governance arrangements are clunky and inefficient, or that they feel they have pushed the bounds of the existing legislation to its limit, and cannot progress with their vision further without some change.
Despite best efforts, integrating non executive challenge into system governance arrangements is proving difficult. Although the most advanced systems have created reference groups for non-executive directors (NEDs), lay people and councillors, and some trusts have allocated a NED lead for the different place based systems within the STP footprint, we have not come across a robust example of an STP/ICS integrating the challenge and scrutiny function provided by NEDs within a provider board setting, at system levels. NEDs of course continue to play a central role in supporting and challenging decisions made by their trust board with regards to system plans. Another interesting characteristic is the increasing emergence of executive chairs or STP chairs, with some STPs making use of independent individuals to help facilitate agreement and direction.