Last reviewed 20 October 2021
In September, NHS England and NHS Improvement (NHSEI) published guidance on how to achieve the vision of a fully inclusive, multi-professional clinical and care leadership role, working equally with local government, social care and other partners, in developing and delivering the transition from clinical commissioning groups (CCGs) to the new statutory Integrated Care Systems (ICSs) from April 2022.
The new guidance covers clinical and care professional leadership, place-based partnerships, and Integrated Care Board (ICB) approaches to working with people and communities, and with the voluntary sector.
A previous Croner-i feature in this series explained NHSEI’s earlier guidance on developing ICSs as legislated for in the Health and Care Bill, which is at committee stage in Parliament. It covered the functions and governance of the ICBs, and the HR framework for developing the ICBs and provider collaboratives.
NHS Providers, the membership organisation for NHS hospital, mental health, community and ambulance services in England, pushed hard for clinical expertise to be “front and centre” in ICB and wider system governance arrangements, and stressed how clinicians are skilled system leaders in their own right as well as bringing special expertise to decisions such as redesigning and transforming services.
This NHSEI guidance supports the development of distributed clinical and care professionals (CCPs) leadership across ICSs, and helps to ensure these leaders are integrated into decision-making, sharing and contributing towards a “collective ambition for the health and wellbeing of the population”.
Firstly, NHSEI expects system leaders to agree a local framework and associated development plan for CCP leadership with partners across the ICS. The ICB board’s medical director and nursing director are then expected to ensure leaders from all CCPs are involved and invested in the work of the ICS.
To guide the development of locally determined ICS arrangements, the guidance sets out five core design principles together with “what good looks like” criteria.
Principle 1: Integrate CCPs in decision-making at every level of the ICS.
Principle 2: Create a culture of shared learning, collaboration and innovation, working alongside patients and local communities.
Principle 3: Ensure CCP leaders have appropriate resources to carry out their system role(s).
Principle 4: Provide dedicated leadership development for all CCP leaders.
Principle 5: Identify, recruit and create a pipeline of CCP leaders.
The guidance says targeted improvement funding will be allocated to systems in the second half of 2021/22 to support the implementation.
NHS Providers stressed that “seed funding” in 2021 will be vital to help train individuals to take on these new roles, and there will need to be sufficient system leadership development budgets and a rigorous focus on building a diverse and inclusive leadership community.
In its briefing, Further Guidance on Integrated Care Systems (ICSs), Including Place-based Partnerships, NHS Providers praised NHSEI’s approach to providing an enabling, rather than a prescriptive, framework and welcomed recognition in the guidance that systems should avoid duplicating existing CCP network arrangements.
The NHS Confederation also welcomed this guidance. As NHS Confederation Senior Clinical Advisor Dr Graham Jackson said, "clinical leadership is the golden thread that weaves all parts of the ICS together”, and the guidance is seen as a positive “first step” to helping CCP leaders “collaborate and innovate to produce the best shared learning and outcomes”, ensuring they have the time, space and resources to do this.
“Places” are the foundations of ICSs. The boundaries, membership and functions of the place-based partnerships will be locally determined. Partners are being asked to agree a “shared vision” at place level, identifying their purpose and role in the system, and collaboratively define their geographic footprint. Initial proposals for arrangements for 2022/23 need to be confirmed by ICS leaders as part of their ICS development work in 2021/22.
The guidance has a bottom-up approach, supporting all partners in ICSs to collectively define and evolve their place-based working arrangements, activities and governance.
It proposes possible governance arrangements including consultative forums, joint committees and lead provider models, which should be determined by local partners following the passage of legislation.
Activities that place-based partnerships can lead include coordinating the planning and delivery of integrated services, allowing trusts and their partners to continue to develop arrangements that suit their local populations and circumstances. Place-based partnerships are also expected to build and maintain broad coalitions with wider community partners to influence the wider determinants of health.
Although ICBs, NHS providers or local government can delegate statutory functions and budgets to place-based partnerships, they will still retain accountability for all of these functions.
NHS Providers called for more clarity around what the place-based partnerships are accountable for and to whom, especially if they have a role in monitoring performance. The organisation also expressed concern that the guidance may have too narrow a focus on health and care services in a locality before acknowledging the importance of building “broader coalitions”, such as with housing associations and education providers, to promote health and wellbeing.
NHSEI has published useful learning from place-based partnerships, here.
All ICBs are expected to develop a system-wide strategy for engaging with people and communities by April 2022.
This guidance describes the principles, core requirements and good practice to support ICSs to listen and act on the experience and aspirations of local people and communities.
It also covers arrangements for engagement in ICB constitutions, and ensuring that ICPs and place-based partnerships have representation from people and communities in key forums.
NHSEI has added three principles for developing the approach to working with people and communities to an original list of seven principles in the ICS Design Framework.
Put the voices of people and communities at the centre of decision-making and governance at every ICS level.
Start engagement early when developing plans and feed back to people and communities how engagement influenced activities and decisions.
Learn from what works and build on the assets of all ICS partners.
By April 2022, ICBs are expected to have developed a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making arrangements, ideally through a VCSE alliance. NHSEI says these arrangements should build on the involvement of VCSE partners in relevant forums at place and neighbourhood level.
The biggest challenge for the VCSE sector is funding, following the impact of the pandemic on fundraising, and communities and the health and care system now need a robust VCSE sector to support people’s health and wellbeing, according to NHS Providers.