Providers play a key role in ICSs. Recent NHSE guidance reinforces the expectation that provider collaboratives, along with place-based partnerships, will be key to enabling ICSs to deliver their core purpose and meet their triple aim.
In accordance with guidance, as well as the 2022 Act, providers can collaborate without the agreement of their local ICB(s). In practice, providers can work collaboratively on programmes or activities outside of more formalised collaborative arrangements and without involvement of the system. The same can be true for more formalised provider collaboratives, collaborating without involvement of the system, or without including all providers within the system.
However, there are many examples of provider collaboratives working in and through system-wide governance structures to deliver on system-wide, or cross-provider programmes. Provider collaboratives often sit as part of the delivery infrastructure of the ICS, alongside place-based partnerships. The ICS design framework[1] sets out the expectation that "provider collaboratives will agree specific objectives with one or more ICS, to contribute to the delivery of that system's strategic priorities", with the provider collaborative establishing how this contribution will be made. It remains between the system and the provider collaborative to define the working relationship and the governance arrangements.
In some instances, 'responsibility agreements' are used to set out the specific areas of focus, work programmes and resourcing jointly agreed between the ICB and provider collaborative. It may be appropriate that the ICB supports the provider collaborative by contributing to the programmes resourcing either financially and/or through staffing. This is particularly the case when the collaborative is delivering against key system strategic objectives, or where there are links to programmes being delivered through a sub-committee of the ICB. An example of this is where systems have established mental health, learning disability and autism programmes or boards, coordinated by the ICB, with input from wider system partners, with services delivered through the provider collaborative.
Positive relationships between system partners are considered key to effective provider collaboratives. But this experience, and the frequency of collaboratives' engagement with their ICB is likely to vary depending on a range of factors including the maturity of the ICB and the scope of the provider collaborative.
Greater complexity is likely to come for those provider collaboratives spanning multiple systems. This will come from balancing the relationship-building, potentially differing priorities, and engagement with system partners across a larger footprint.
ICB to provider delegation
The 2022 Act introduced new delegation powers. Sections 65Z5 and 65Z6 of the Act allow ICBs and trusts to delegate their functions to each other, jointly exercise functions and form joint committees. Delegatees are legally liable for the exercise of the specified functions, but delegators retain overall accountability.
The delegation guidance published in September 2022, recommended that systems should not make use of ICB powers to delegate to trusts. At the time of publication, NHSE has continued the hold on the formal use of delegation, to ensure that the right processes and legal requirements are in place to safeguard standards, providers, and systems.
Notwithstanding the hold on delegation under the 2022 Act, ICBs and providers can establish collaborative working arrangements through a number of approaches which are able to achieve similar if not the same aims as can be achieved through formal delegation. These arrangements include:
- Outcomes-based commissioning where a contract sets out what the provider is expected to achieve (sometimes used in service redesign).
- Lead provider model (covered later in this guide) in which a single trust takes on contractual responsibility (on behalf of a provider collaborative) from the ICB for an agreed set of services, and subcontracts to other providers as required.
- Conferral of discretions in which providers are able to determine the services they deliver under a contract, and how they are delivered.
- An ICB committee or sub-committee including providers where an ICB arranges for its functions to be exercised through a committee or sub-committee which can include members who are not employees of the ICB [2].
- A joint committee between ICB(s) and providers or solely between providers which can exercise functions those bodies have agreed to exercise jointly through the committee, allowing binding shared decisions.
Once powers are made available for formal ICB delegation to take place, this could mean delegation of functions such as quality improvement, patient involvement or 'arranging' functions, which gives providers the ability to assess population needs, design services or decide what services are necessary. This enables providers to play the traditional role of commissioner in contracting with other providers for key system services on behalf of the system, while not directly providing any of these services.
[1] ICS Design Framework (2021)
[2] Para 11 of Schedule 1B to the NHSA