Last reviewed 18 November 2020

In this feature, Thoreya Swage, Healthcare Consultant, describes the building blocks of Integrated Care Systems in England.


Since 2016, across England, health and social care has been working together in an integrated manner, beginning as Sustainability and Transformation Partnerships. By April 2021, the whole country will be covered by Integrated Care Systems (ICSs); 44 in total.

What is an Integrated Care System?

An Integrated Care System (ICS) is one in which a group of commissioners and providers agree to be responsible for the planning and provision of all care, for a defined population. The ICSs 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.

The decisions are made at three main levels within Integrated Care Systems.

  • Primary Care Networks: for populations of 30,000 to 50,000.

  • Places: for populations of 250,000 to 500,000.

  • System: for populations of 1 million to 3 million.

The development of an ICS is assessed by a maturity matrix, covering four domains; oversight, planning, finance and support, which brings together co-ordinated, system-wide working for their populations. This is underpinned by an agreed system budget (or control total) and where performance and quality are assessed on a system-wide basis by NHS England/Improvement and the Care Quality Commission.

As ICSs have been maturing, their focus has consolidated into three areas of work or pillars.

  • Primary Care Networks

  • Personalised Care

  • Population Health Management

Primary Care Networks (PCNs)

What are Primary Care Networks?

PCNs 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.

PCNs form the basic unit of delivery of health and social care within an ICS. PCNs enable closer working between practices and community services within the network and provide enhanced care around home care residents, rehabilitation, extended hours, reducing unnecessary admissions to hospital, management of long-term conditions and use of digital technology and new tools, such as social prescribing.

PCNs have been working very closely with their health and social care colleagues in response to the first wave of the Covid-19 pandemic in, for example, facilitating hospital discharge and providing urgent care together with community services.

Personalised care

What is personalised care?

This is about enabling people to make their own choices about the care they receive, supported by professionals and the system.

This approach is supported by 10 years of evidence-based research studying not only closer working between health, social care and public health, but also the contribution of the voluntary and community sector to support people and build resilience. Personalised care has been shown to:

  • enhance health and wellbeing, link up care in local communities and help health and social care to become more efficient

  • enable people with mental health conditions and physical disabilities to make decisions about their own health so that they can live the lives they want to live

  • widen the scope of help and support people can get to more than health and social care

  • bring together the different parts of the health system.

The delivery of personalised care is envisaged to become “business as usual” within health and social care systems by 2023–2024. This will be implemented through the Comprehensive Model of Personalised Care.

The Comprehensive Model of Personalised Care is a whole population approach to delivering support to people with physical and mental health conditions of all ages and enabling informed decision making about their care. It permits personal choice and control over the care they receive.

The model brings together six evidence-based elements or programmes that are defined by a standard set of practices.

  • Decision-making that is shared: where a clinician supports a patient to reach the best decision about their care that is appropriate for them.

  • Care that is personalised and planning for support of patients: where there are facilitated discussions between the person or people who know them well to look at the management of their health and wellbeing in the context of their social situation.

  • Helping people to make informed choices about their health, including their legal rights.

  • Social prescribing: where people are directed to bodies or organisations in the community, eg the council or voluntary sector to improve health and wellbeing.

  • Self-management that is supported: where the skills, knowledge and confidence people have in themselves is identified and harnessed to manage their own health and care.

  • Personal health budgets: where people have an identified amount of money to support their health and wellbeing needs (agreed between the person or representative, and the local Clinical Commissioning Group).

Although these are national standards, there is flexibility to modify for local adaptation.

It is anticipated that universal personalised care will benefit up to 2.5 million people by 2023–2024, with 200,000 having a personal health budget, 750,000 having personalised care plans and over 1000 trained social prescribers in place.

Population Health Management (PHM)

Health and ill-health are determined by more than just the presence of physical and mental conditions. In fact, only 20% of health outcomes are affected by access to good quality health care. The “wider determinants” of health, eg housing and employment, have a large impact on personal health and wellbeing.

Examining the wider determinants of health through Population Health Management (PHM) provides the bigger picture of the health of local communities. PHM uses historical and current data to identify the factors that drive poor outcomes in different populations. This then informs the development of new models of care which enhance health and wellbeing of people for short- and long-term planning. It also ensures that public resources across health and social care, and other public sector organisations (eg local councils, housing associations, fire service, police etc) are used as efficiently as possible.

Integrated Care Systems — the future

It is clear that integrated working across health, social care and other public services are here to stay and will continue to play a key role in the planning and delivery of care in England.

Since the concept of integrated working was introduced, development of ways of working and co-operation has varied across the country. This is due to factors such as historical relationships and the fact that ICSs are made up of many different organisations with their own statutory duties which sometimes may conflict with effective joint working. The changes in the NHS Long-Term Plan set an expectation of enhanced working but with these factors in place movement has been slow.

However, the advent of Covid-19 had the impact of accelerating the changes, as it soon became apparent that different parts of a health and social care system working separately would not be effective in responding to the challenges presented by the pandemic.

The Covid-19 pandemic has cut through differences and difficult relationships, and facilitated new ways of working, eg managing urgent care, virtual consultations, enhancing discharge from hospital, and improving delivery of care in community and general practice.

As the NHS faces the winter of 2020–2021 and a second surge of Covid-19, the challenge will be to capture and sustain this joint working for the benefit of patients and the public.