Last reviewed 13 January 2021

In this feature Thoreya Swage, Healthcare Consultant, describes the next phase of development of Integrated Care Systems for 2021–2022.

Background

The NHS Long-Term Plan set out a map for the development of locally joined up health and social care, centred on people’s needs in England.

In November 2020, a Croner-i feature article was published on the continued development of Integrated Care Systems (ICSs) which outlined the three levels of working.

  • Neighbourhoods/Primary Care Networks (PCNs): the basic unit of delivery of health and social care within an ICS comprised of groups of GP practices working as a PCN, each covering populations of 30,000–50,000.

  • Place: where PCNs work with each other, and other health and social care services within a district or town, covering populations of 250,000 to 500,000.

  • System: where the whole area’s health and social care partners in different sectors work together providing information on population health management, covering 1 to 3 million.

In December 2020, NHS England and NHS Improvement published a document Integrating Care: Next steps to building strong and effective integrated care systems across England, which describes the further development and possible legislative changes needed to embed the collaborative working between health and social care.

The proposed changes

The changes that are proposed are the result of experiences of ICS leaders and the lessons of Covid-19 on collaborative working.

The key changes are:

  • place-based working

  • provider collaboratives

  • strategic commissioning

  • effective use of digital data.

The key theme of these changes is to incorporate the good practice and to support the effective ways of working that some systems have developed, together with allowing flexibility for local solutions to emerge rather than imposing a top down approach.

Place-based working

Place-based working is dependent on strong partnerships between all the stakeholders involved in contributing to the health and social care needs of the place. This includes primary care, local authorities (including public health), community and mental health providers, and Healthwatch.

The designated place leader will have four main roles.

  • To support and develop PCNs.

  • To join up health and social care through technology, amongst other things.

  • To identify and support people and families at risk of being left behind, using techniques such as population health management.

  • To coordinate the local health, social and economic development to focus on prevention in different population groups.

Each place will have autonomy, resources and decision-making capabilities which would include delegated budgets working within an ICS funding and accountability framework.

Place-based leadership has:

  • joined up decision-making arrangements for specific functions

  • at a minimum, involvement from primary care, local authorities (including public health), community and mental health providers, plus Healthwatch

  • joint decision-making processes with local authorities

  • ICS board representation.

The boundaries and sizes of places are locally defined and can include other partners such as the acute sector, ambulance trusts and the voluntary sector. Each place can determine its own precise governance and decision-making arrangements and voting arrangements at an ICS board.

Provider collaboratives

The objective of providers working together is to reduce variation in access, enhancing workforce planning and corporate functions. This will include agreeing service redesign and clinical pathways. All NHS trusts are expected to become part of a collaborative.

Provider collaboratives will be made up of NHS provider trusts and can be horizontal, ie formed of providers of the same type, such as acute services within an ICS or vertical, ie formed of different types of providers such as community, mental health and acute trusts at the level of the place. Providers may be part of vertical collaboratives (at place level) and horizontal collaboratives at ICS level.

Provider collaborative leadership has:

  • joined up decision-making arrangements for specific functions

  • ICS board representation.

Each provider collaborative can define its scale, scope and actual membership. Like place working, each collaborative can determine its own precise governance and decision-making arrangements, and voting arrangements at an ICS board.

Each organisation will continue to carry out its statutory functions.

Strategic commissioning

Increasingly, decision on priorities and resources will be taken at an ICS level. This will mean that funding for primary care, and commissioning acute, community and mental health services will be allocated to ICSs which will then allocate budgets to places as a whole. By having place budgets this permits flexibility across providers within the patch to shift resources across a pathway to drive transformation and to target priority areas such as mental health and primary care. An example of this is agreeing to manage collectively waiting lists across the ICS and urgent and emergency care.

As a consequence, ICSs will be undertaking a system-wide strategic commissioning role by assessing health needs, addressing health inequalities and directing funding at priority areas. Contracts with providers will become outcomes focused, not transactional.

As commissioning decisions move to an ICS level, the role of Clinical Commissioning Groups (CCGs) diminishes and there is a need to provide greater clarity on the role of ICSs. There is also a need for ICSs to become enshrined in legislation. Two options are proposed.

  • To make a statutory committee with an Accountable Officer bringing together the CCGs at a strategic level. This will enable the ICS, through the mechanism of a joint committee, NHS commissioners and providers and local authorities to take collective decisions.

  • To make the ICS a statutory corporate NHS body that brings the CCG functions into it (ie taking over the CCG’s responsibilities).

ICS leadership

Many ICSs are currently working in an informal way through system wide partnership boards. The document is proposing that this is placed on a firmer footing with the partnership boards having representation not only from the provider collaboratives and leadership from the place-based localities but also from the voluntary sector, and input from lay and resident members.

This partnership board will enable collective decision-making, and provide leadership, and quality and financial governance at a strategic level. The partnership board will have an overall view of what is happening within the ICS with decision-making delegated to the place and provider collaborative level.

Clinical and professional groups will have a strong leadership. This will include PCN leadership that build partnerships in neighbourhoods covering general practice, dentists, optometrists and pharmacists, as well as community and mental health care.

Digital and data

The experience of managing care through a pandemic has enabled rapid transformation from a face-to-face way of working and moving, where possible, to remote working collaborating with system partners.

This is now to be built on and supported by a system wide three-year digital transformation plan which includes the upskilling of the workforce in digital and data literacy, shared care records, cross system analytical and intelligence functions, and enabling people to take a greater part in their care, eg remote monitoring of their long-term conditions, information on how to stay healthy and well, and access to health and care services.

The next steps

Whilst legislative action is required to place the ICS on a statutory footing, closer collaboration between PCNs, places and provider collaboratives can continue to develop.

It is anticipated that many of these changes will be in place by April 2022.