From the day they were put on a statutory footing in summer 2022, integrated care systems (ICSs) have been tasked with managing structural and governance change alongside significant financial and operational pressures.
In this challenging context, it is not surprising that many ICSs are still in the early stages of realising the ambitions of system working: to improve population health, drive value for money, tackle inequalities and help the NHS support broader social and economic development. But strengthened collaboration and partnerships are nevertheless already starting to support resilience in the health and care system to benefit patients.
Trust leaders' contribution will be central to the success of systems, but how can they build on this early progress and make the most of the opportunities system working offers? Through recent interviews and surveys, trust leaders have told us the recipe for success needs the following three ingredients:
Clear roles and responsibilities within systems
Trust leaders support the spirit and direction of greater collaboration within systems. But as new system working arrangements bed in, they tell us that roles and responsibilities within systems are not yet entirely clear. Reflecting this, only a third (35%) of respondents to our recent governance survey of company secretaries say their trust board is confident there are clear roles for trusts, integrated care boards (ICBs), integrated care partnerships, place-based partnerships and collaboratives. Greater clarity around the roles within systems is key to reducing duplication (particularly between ICBs and NHS England regional teams), and to maximising the effectiveness of partnerships and decision making.
Trust leaders are also concerned about ICBs taking on a performance management role. In our July survey on Improving regulation for the future, only 37% of respondents reported they were comfortable with the role of ICBs as performance managers. This compares to 87% who said that ICBs should facilitate improvement and peer support of individual providers. This may run contrary to the likely direction of travel but there is a clear view within the provider sector that ICBs cannot effectively be both a convener and performance manager, and that more value can be added by working with ICBs as equal partners.
Strong voice for trusts in ICBs
Trusts are employers managing significant budgets as well as service providers. Their voice is therefore essential to successful system working.
Over two thirds (68%) of governance survey respondents agree that their trust board can influence the development of the system(s) they are part of. This feedback is positive, suggesting there is more work to do for a sizeable minority.
For trusts with board members who also hold system-level positions, there is clearly more opportunity to influence the development of system working and engage within the ICB. The ICB trust partner member role is central to this. Our recent round of interviews with trust leaders who are also partner members on an ICB, suggests these new positions can prove to be interesting roles but come with challenges, especially on defining the scope of the role and managing conflicts of interest.
The level of influence within a system experienced/reported by providers also varies across different sectors. For instance, 42% of respondents to our governance survey said they have board members from their trust undertaking a joint/shared post within their system(s), but this was just 17% among community trusts, perhaps reflecting a need for the value of community services to be better promoted in system level conversations.
Realising the potential of provider collaboratives and place-based partnerships
Trust leaders tells us they are making a significant contribution to provider collaboratives and place-based partnerships, which are key vehicles for delivering ICS priorities. A large majority (80%) of governance survey respondents report having a board member who is also part of a formal provider collaborative or place-based partnership leadership.
In the same survey, over a third (38%) of trust leaders report that their provider collaborative(s) and/or place-based partnerships are delivering measurable patient benefits. Similarly, our State of the provider sector survey found that ICSs were central to winter planning and capacity sharing this year, with over half of respondents saying their provider collaborative(s) are effective in managing operational pressures. This is vital given the current challenges, and impressive given that many of these collaborative ways of working are relatively new.
In terms of next steps, trust leaders highlighted more effective use of resources through collaboration and said they have some way to go to support the recruitment and retention of health and care staff, a key system priority.
In summary, trusts are making an important contribution alongside system partners, joining ICBs and leading place-based partnerships and provider collaboratives. As we head into what is widely expected to be the most pressurised winter trust leaders have experienced, these relationships will be key to building more efficient, resilient and responsive services.
This opinion piece was first published by HSJ.
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