In this feature Thoreya Swage, Healthcare Consultant, describes the next stages of development of Integrated Care Systems.
Since 2016 across England, health and social care services have been working together in an integrated manner as Sustainability and Transformation Partnerships (STPs). This offers a practical and realistic way of planning and delivering care crossing the traditional boundaries of primary and secondary care, mental health and social care, as well as placing a greater emphasis on self-care and supporting people to live healthier and more independently through prevention initiatives. Forty-four STPs were established across the country which are at various stages of maturation.
The NHS Long-term Plan, published in January 2019, set out the ambition for the further development of these Sustainability and Transformation Partnerships (STPs). Building on the STPs that had progressed faster and that had demonstrated closer working amongst the constituent organisations, the strategy described the ambition to accelerate this model of working through the development of Integrated Care Systems (ICSs).
In 2018, fourteen ICSs had emerged which covered a wide range of geographies (urban and rural), different sizes of population, as well as in two areas (Greater Manchester and Surrey) in which there were devolved health agreements.
What is an Integrated Care System?
An Integrated care System (ICS) is one in which a group of commissioners and providers agrees to be responsible for the planning and provision of all care for a defined population for a given period of time. These ICSs or ‘place-based’ partnerships work within an agreed pooled budget and are held accountable for achieving quality outcomes through more effective use of resources in order to improve the health and wellbeing of their local populations.
Progress on developing ICSs
Since the publication of the NHS Long-Term Plan, NHS England and NHS Improvement have been facilitating the continued development of STPs using an approach that ensures a consistent methodology in their transformation into ICSs.
In June 2019, a further three ICSs were approved by NHS England making a total of 20 million people covered by integrated working.
The NHS Long-term Plan has set out the expectation that by April 2021 the whole of England will be covered by an ICS.
How do Integrated Care Systems work?
NHS England and NHS Improvement have identified the three main levels at which decisions are made within Integrated Care Systems:
Neighbourhoods/Primary Care Networks
Neighbourhoods are seen to be the basic unit of delivery of health and social care within an Integrated care System. They are envisaged to be comprised of groups of GP practices usually working as a Primary Care Network with a population of 30,000 – 50,000 in size.
What are Primary Care Networks?
Primary Care Networks are groups of neighbouring GP practices working together to provide primary and community services to a wider population than a single practice in order to improve outcomes for their local patients.
Primary Care Networks have a wider remit compared to traditional GP services by offering urgent community response and rehabilitation through, for example, providing NHS support to care home residents, extended hours access, reducing unnecessary admissions to hospital, the use of digital technology and new tools such as social prescribing. There will be a greater emphasis on helping people to care for themselves and for the delivery of services to be as close to people’s homes as possible.
The next level is the ‘Place’ where the Primary Care Networks work with each other and other health and social care services within a district or town. Typically, the size of a Place would be about 250,000 to 500,000 in size.
A Place may be co-terminus with a local authority boundary or a larger natural geographical area where services are delivered. It would include not only Primary Care Networks but also hospital care, mental health and community providers, local government and local voluntary organisations.
A Place will be charged with the responsibility of conducting a shared assessment of local needs and a plan to deliver services using their joint resources beyond traditional health and social care. A Place will be successful if there is robust collaboration and joint decision-making in the redesign of clinical care pathways and through the use of population data to understand the wider determinants of health such as housing, employment, environment as well as identifying training requirements.
It is also envisaged that co-ordinated rapid response teams are established to provide a service to support people with learning disabilities.
This way of working at a Place level is not based in statute and therefore commissioners (Clinical Commissioning Groups and local authorities) are not able to have legal decision-making powers together with other statutory providers. So ‘boards’ at this level are required to operate using a memorandum of understanding or an NHS alliance agreement. Health and Wellbeing Boards, which bring together local leaders from different parts of a system have a statutory footing and so ICSs are expected to work closely with these forums. Often Health and Wellbeing Boards have similar boundaries to the Place level.
At a strategic level, the whole area’s health and social care partners in different sectors work together for a population size of between 1 million to 3 million people to take advantage of economies of scale.
The size and shape of the Integrated Care Systems vary with the number of Places and total ICS populations across the country; the exact configuration being dependent on local factors such as natural geographical boundaries, working relationships which have worked effectively in the past and need.
Systems that are most mature reflect the historical ways of joint working on a local level that have been in existence over a number of years, usually facilitated by Joint Strategic Needs Assessments and well-functioning Health and Wellbeing Boards.
In addition, the fifty Vanguards that have been refining and testing various models of care have fed into the development of ICSs.
What are the Vanguards?
The vanguards are the testbeds for new models of care that have been developing as part of the NHS Five Year Forward View. They include:
Multispecialty Community Providers (MCPs)
MCPs comprise of groups of practices working together in order to provide enhanced primary and community services over and above the standard GP contract using different clinical healthcare professionals supported by digital technology.
Primary and Acute Care Systems (PACS)
This involves many organisations, including general practice, hospital, mental health and community services, coming together to provide care for their populations. It through the learning from these integrated care models that STPs and ICS have emerged.
Enhanced Care for Care Homes
These include in-reach support, such as medical and medication reviews and rehabilitation, provided jointly by the NHS and care home sector, to reduce the need for hospital admissions.
The STPs and ICSs depend on collaborative leadership from all parts of the system and are most effective when the different levels support and complement each other.
At the system level there is strategic leadership covering the whole of the ICS population. A single plan describing the long-term transformation and operational priorities should be built on the plans developed at Place level. In addition, all partners (CCGs and NHS Providers) should sign up to a system control total thereby enhancing joint accountability for managing the finances.
The system is also responsible for ensuring access and delivery of high-quality services, minimising unwarranted variation in clinical care and outcomes, and tackling health inequalities. Other functions include NHS workforce planning at the systems level, agreeing and managing the best use of estates, capital funding and digital infrastructure, such as joint record sharing. It is expected that good practice emerging from one part of the system will be spread across the ICS.
The system is best placed to support clinical, managerial and support roles where these can be most efficiently and effectively delivered, for example in business intelligence or analytical capacity functions. It is in this capacity that Commissioning Support Units can best support ICSs.
To support system wide-working, joint governance arrangements (usually through a system-wide board including all NHS partners) need to be in place to facilitate the collective responsibility of the ICS leaders for financial and operational performance
Support and oversight
The ICSs will be held to account for their decisions, as well as being supported in their development by NHS England and NHS Improvement. System-wide objectives will be agreed with, and monitored by the Regional Director.
Nationally NHS England/Improvement will support their regional teams to facilitate the continued development of ICSs by encouraging greater collaborative responsibility for focusing on the health of the population, enhancing the quality of care and effective use of NHS resources.
Issues of quality, safety and performance will be focused at the system level as much as possible.
System level accountability by NHS England/Improvement Regional Teams
Managing system development and performance will initially be the responsibility of the regional teams, although as the ICSs mature this will shift to the system itself. Approaches to regulating systems will therefore vary depending on their maturity, with the more mature systems having greater autonomy. In this scenario, the regions will engage less with the individual organisations and reduce the number of formal meetings.
There will be some functions such as ambulance services, specialised commissioning or emergency preparedness that may be better managed at sub-regional level (bigger than system-wide) depending on the scale of delivery or need.
As systems take on more self-development and self-assurance, the NHS England and NHS Improvement regional teams will become leaner and more strategic. The national NHS England/Improvement team will continue to focus on strategy and policy development including that of systems, NHS providers and commissioners.
In order to facilitate the development of systems into mature Integrated Care Systems a maturity matrix has been formulated.
This framework identifies the core capabilities of development, including: emerging ICSs, developing ICSs, maturing ICSs and thriving ICSs. A system is said to be formally an ICS when it meets the attributes of a maturing ICS.
The matrix describes a journey rather than a set of checklists, acknowledging that not all of the domains will be met at the same pace and therefore ICSs will be at varying levels of maturity across each domain. This encourages more subtle and reflective discussions about the maturity of systems.
There are five domains which cover:
Leadership of the system, partnerships and capability for change
Architecture of the system and financial planning and management
Integrated models of care
Track record of delivery of national priorities, constitutional standards, financial management and health outcomes
Defined and coherent population over which there is close working across local authority boundaries
Criteria for formally naming systems as an ICS
There are four areas which systems are required to meet in order to be formally named as an Integrated Care System. It is expected that all systems will have achieved this level of maturation by April 2021.
The four areas together with the level of development are described below:
Area of development
Characteristics of a maturing ICS