Last reviewed 10 September 2021
NHS England and NHS Improvement (NHSEI) have published guidance in August 2021 on developing the new Integrated Care Systems (ICSs), as legislated for in the Health and Care Bill that is now entering committee stage in Parliament.
Preparations are gathering pace in establishing ICSs with the primary objectives of:
improving outcomes in population health and healthcare
tackling inequalities in outcomes, experience and access
enhancing productivity and value for money
helping the NHS support broader social and economic development.
NHSEI is laying the foundations for the new systems by publishing:
the functions and governance of the Integrated Care Boards (ICBs), which will bring the NHS together locally to improve population health and care
an HR framework for developing the new ICBs
guidance on provider collaboratives
guidance on the ICS people function.
More guidance on effective clinical and care professional leadership, place-based partnerships and ICB approaches to working with people and communities is being launched in September.
Recruitment of all ICB members will be completed by the end of the third quarter in 2021/22, so that they are ready to operate in “shadow form”, with all other leaders to be recruited by the end of the fourth Quarter.
GP representative bodies have been watching the direction of the design of the new statutory bodies closely and their initial responses focus on the strength of the voice of clinicians and general practice in decision-making capacities. Following the publication of the ICS Design Framework in July, the British Medical Association (BMA) felt these early plans were falling short in respect of clinical leadership and representation, with no mention of LMCs or LNCs.
August 2021 ICS Guidance Documents
The Interim Guidance on the Functions and Governance of the Integrated Care Board confirms the minimum requirements for ICB governance and board membership as outlined in the Bill and the ICS Design Framework.
It also sets out current expectations regarding board appointments and membership, the clinical commissioning group (CCG) functions expected to be applicable to ICBs, and more detail on other considerations for ICB governance arrangements such as managing conflicts of interest.
Subject to the legislation being agreed, each ICS will comprise two system-level elements.
An Integrated Care Board (ICB).
An Integrated Care Partnership (ICP).
Integrated Care Boards (ICBs)
Statutory functions currently exercised by CCGs will be conferred on ICBs from 1 April 2022. ICBs will also “bring health and care organisations together in new ways” with a greater emphasis on collaboration and shared responsibility for the health of the local population.
From April 2022 it is also expected that ICBs will assume delegated responsibility for Primary Medical Services, currently delegated to all clinical commissioning groups (CCGs), and continuing to exclude Section 7A Public Health functions, as well as delegated responsibility for dental, general optometry and pharmaceutical services, including dispensing doctors and dispensing appliance contractors.
CCGs will be legally responsible for the development of ICB constitutions throughout the year, with final versions approved before the end of the fourth quarter by NHSEI.
The function of the ICBs will be to develop a plan to meet the health and care needs of the population within their area, “having regard to the Partnership’s strategy”, and allocate resources to deliver the plan across the system. Throughout the year, they will develop a “functions and decision map” showing the arrangements with ICPs to support good governance and dialogue with internal and external stakeholders.
Discussions with partners and decisions on commissioning arrangements at system and place are to be finalised by the end of the third quarter.
The guidance says ICBs will have a range of activities including supporting the development of primary care networks (PCNs) as the “foundations of out-of-hospital care and building blocks of place-based partnerships, including through investment in PCN management support, data and digital capabilities, workforce development and estates”. They are also putting contracts and agreements in place to secure delivery of their plan by providers, and convening and supporting providers, working at scale and at place, “to lead major service transformation programmes to achieve agreed outcomes”.
ICS Board Recruitment
Each ICS has to agree its own constitution with NHS England. Its ICB will have a unitary board, so all directors are collectively and corporately accountable for an ICS’s performance and have responsibility for ensuring its functions are discharged.
Minimum requirements for ICB board membership will be set in legislation but further minimum expectations for membership are set out in this guidance.
NHSEI says: “ICBs have been created to give statutory NHS providers, local authority and primary medical services (general practice) nominees a role in decision-making”. Therefore, the boards of ICBs will include a “minimum” of three partner members with “at least” one from GP providers, one from NHS trusts or foundation trusts and one from the local authority with statutory social care responsibility.
All three partner members will be full members of the unitary board, bringing knowledge and a perspective from their sectors, but not acting as delegates of those sectors.
The boards will also include a Chair and a minimum of two other independent non-executive Directors who do not normally hold positions in other ICS health and care organisations, and four executive roles including a Medical Director and Nursing Director. NHSEI said it expects every ICS board to establish roles above the minimum level in order to “carry out its functions effectively”.
And NHSEI expects “the member drawn from primary medical services providers to engage and bring perspectives from all primary care providers, including primary care networks (PCNs).” This is welcomed by the BMA.
Each board will also be required to establish an audit committee and remuneration committee.
Accountability and Openness
The BMA has raised concerns regarding existing ICSs’ lack of accountability. However, it believes this should be addressed in part by their transition to statutory status, and much is expected in terms of accountability and transparency in this guidance.
All board members are to be selected based on skills and experience required to fulfil the roles, and must meet the “fit and proper persons” test and the eligibility criteria set out in the constitution of the ICB.
In addition to the required board roles, the ICB is expected to establish leadership structures and accountability for the organisation’s responsibilities in delivering the agreed local and national priorities.
The guidance is in line with the BMA’s call for ICSs to be led by NHS and publicly accountable bodies. The personal and professional interests of all ICB board members, ICB committee members and ICB staff who are involved in decision taking need to be declared, recorded and managed appropriately, and any individual involved in decisions relating to ICB functions “must be acting clearly in the interests of the ICB and of the public, rather than furthering direct or indirect financial, personal, professional or organisational interests.”
Committees of the ICB can be established to support the board and exercise any delegated functions. This is likely to include arrangements for committees and groups to advise the board. The BMA has noted the option of various committees in terms of GP representation, where “clinical voices can and should also be amplified”.
Integrated Care Partnerships (ICPs)
Each ICS area will have a system level ICP, which is a committee established jointly by the ICB and relevant local authorities. The ICP is broad alliance of organisations and representatives concerned with improving the care, health and wellbeing of the population, and has a specific responsibility to develop an integrated care strategy.
Each ICB has to align its constitution and governance with the ICP, and will consider evolving membership of the ICP as is required to best meet the needs of the local population.
The BMA said the very limited focus on ICPs was welcome, as was the omission of private providers from the proposed minimum requirements of ICB board membership. It also welcomed the explicit focus on the role of public health experts within the ICPs.
More ICP guidance will be issued by the Department of Health and Social Care (DHSC), jointly developed with NHSEI and the Local Government Association (LGA).
Place Based Partnerships (PBPs)
Place-based partnerships provide a regular forum for linking the work of provider collaboratives with wider system priorities and gathering input from system partners.
It is up to local partners to determine PBP membership, expecting that they will include representation from primary care provider leadership, represented by PCN clinical directors or other relevant primary care leaders, as well as providers of acute, community and mental health services, and people who use care and support services, their representatives including Healthwatch, local authorities, social care providers, the voluntary sector, and the ICB.
Each ICB should set out the role of place-based leaders within its governance arrangements. More guidance on this is being published in September 2021.
The BMA has been calling for further clarity on the role of provider collaboratives, including the services they are likely to provide and what bodies will be able to join them. The NHSEI’s Working Together at Scale: Guidance on Provider Collaboratives provides the detail on this.
Provider collaboratives are partnership arrangements involving at least two trusts working at scale across multiple places with a shared purpose and effective decision-making arrangements. All trusts providing acute and mental health services are expected to be part of one or more provider collaborative by April 2022.
They will agree specific objectives with one or more ICB to contribute to the delivery of that system’s strategic priorities. By working at scale, they offer opportunities to tackle unwarranted variation, make improvements and deliver the best care for patients and communities.
ICBs commission the delivery of services from NHS providers, and members of a collaborative can, as they already do, pool their individual funds to deliver the objectives of the collaborative, or they can use a lead provider model.
Collaboratives are being asked to consider how they will involve and embed the expertise of primary care, the voluntary sector and local authorities. They also offer an opportunity for trusts to consider how they can better support primary care, including working with PCNs to support priorities in prevention, access to urgent and emergency care and whole pathway developments.
Community trusts, ambulance trusts and non-NHS providers can be part of provider collaboratives "where this would benefit patients and makes sense for the providers and systems involved".
Members of a provider collaborative are accountable to each other, are collectively accountable to the populations and communities they serve, and must maintain openness as a way of working with all system partners. Subject to formal consultation, NHSEI will publish further guidance under the NHS provider licence that explains how good governance for trusts includes a requirement to collaborate. It will set expectations for collaboration in areas such as engaging consistently in shared planning and decision-making, and will set out good governance to be in place to support this.