Does the buck stop with integrated care systems?

While we were waiting for the newly published Health and Care Bill to see the light of day, NHS England and NHS Improvement continued to press ahead with guidance to help integrated care systems (ICSs), and their constituent organisations, prepare to launch as statutory organisations.

Wherever you look in the national health and care system architecture right now, significant change is afoot. With a new secretary of state for health and social care and an outgoing NHS England and NHS Improvement chief executive, and forthcoming legislative reform, in the context of intense operational pressures and the pandemic recovery, it's hard to ignore the inflection point upon us.

One area where all these changes coalesce is the next phase of ICS design work and its implementation. Earlier this year the government confirmed that ICSs will have a two-part statutory structure. Each ICS will have an ICS NHS Body, comprised of the organisations that plan and provide NHS services, and an ICS Partnership that will bring together wider partners to align their purpose, ambitions and strategies.

In recent weeks, NHS England and NHS Improvement has published a couple of key policy documents to help local health and care systems navigate this reform. The ICS design framework (16 June) sets out what ICSs will look like once the Bill is enacted and the steps NHS organisations need to take in preparation. The final system oversight framework for 2021/22 (24 June) confirmed that ICSs will develop to lead the oversight and performance management of their constituent organisations. We also still expect technical guidance on the role that provider collaboratives will play in ICSs.

NHS Providers has argued for some time that trusts, working closely with system partners, are the engine room of transformation in local health and care systems.

Miriam Deakin    Co-Director of Development and Engagement

NHS Providers has argued for some time that trusts, working closely with system partners, are the engine room of transformation in local health and care systems. It is encouraging to now see providers front and centre of this latest ICS design phase, building on the success of provider collaboration during the COVID-19 response.

So what do trusts think of this latest tranche of guidance? Overall, they are very supportive of the national vision and direction of travel. It is striking how inspirational trust leaders are when they talk about delivering better joined up care for patients, improving population health and tackling health inequalities in their communities. However, it is clear that the practical detail behind the reforms presents challenges as well as opportunities, and raises some unanswered questions.

1. Will the emerging policy and legislative framework be sufficiently flexible and permissive to allow systems to design what works best for their local population and circumstances? It is encouraging to see this ambition expressed in NHS England and NHS Improvement's guidance, but we'll need to see how this follows through in practice. For trust leaders, a key enabler of collaboration is flexibility. However, there are increasing concerns about the NHS' tendency to centralise, which could lead to an overly prescriptive system architecture – despite everyone's best intentions.
   
   
2. How will this structural reform improve patient care and avoid distracting the sector from service recovery? NHS England and NHS Improvement's board recently cautioned against the Bill becoming "a distraction from our focus on improving NHS care". Trust leaders are similarly unequivocal that funding and oversight arrangements must not displace the focus on better patient access, outcomes and experience, as well as improving population health and tackling health inequalities.
   
   
3. What will the relationship be between provider collaboratives and place-based partnerships? Trusts employ huge numbers of NHS staff and spend the majority of NHS funding. This creates a very real – and welcome – possibility of powerful provider collaboratives and place-based partnerships within ICSs, especially given the potential for delegated decision-making and budgets. While the ICS design framework starts to set out how the two will relate, it's clear that the pull between these different forces will need to be resolved locally.
   
   
4. Where will the ICS land on the spectrum between a collective partnership that serves its members and an oversight body that manages its members? Taken together, the recently published policy documents risk describing ICSs as a separate entity to the providers and other partners comprising them. This language risks moving away from the spirit of genuine partnership between organisations towards an additional management tier. Trust leaders are asking: what is the ICS, if not a sum of its constituent parts?
   
   
5. Where will the buck stop if (and some would say, when) something goes wrong? Ensuring ICSs continue to support the conditions for learning and continual improvement is important. It is also essential that the creation of ICSs with statutory duties does not muddy the current clarity around trusts' accountabilities for the quality of care they deliver, and, as employers, for their staff. Trust leaders continue to question how accountabilities will operate in practice, without overlap or duplication between the ICS and trusts.

In light of these risks, it seems increasingly the case that local action will steer this important phase in ICS development. Trust leaders tell us that they and their partners will do well to focus on three things as they navigate this complex period of change: maintaining clarity of the ICS's purpose, developing the right leadership and culture, and articulating local accountability to populations and system partners. This will keep in sight what we set out to achieve.

This blog was first published by HSJ.