Last reviewed 21 July 2022
The Health and Care Act 2022 has introduced 42 Integrated Care Systems across England, abolishing clinical commissioning groups and transferring their commissioning powers to the new bodies. In this feature, Deborah Bellamy explores what this will mean for health and care services.
Why Integrated Care Systems?
The Covid-19 pandemic has placed untenable pressure on the NHS and made it clear that existing models of care must change to relieve this. Integration and Innovation: Working Together to Improve Health and Social Care for All, in which the Government set out its ambitions for the future of health and social care, states that Integrated Care Systems (ICSs) represent “a critical part of the recovery process from the pandemic”. Since the publication of this paper in 2021, the Health and Care Act 2022 has become law, implementing ICSs and aligning health and care services more closely.
Building a system of collaboration rather than competition, the purpose of ICSs is to support local health and care services within communities to provide holistic, co-ordinated care in a flexible, person-centred way whilst reducing duplication and inefficiencies. In short, the aim of ICSs is to amalgamate services and provide higher-quality care to local communities. Underpinning this are lessons learnt from the Covid-19 pandemic — recognising the value of partnership between local government and voluntary and community services to address the needs of local communities in a less bureaucratic, more accountable way that enables targeted improvements for the delivery of health and social care.
Forming regional partnerships between the NHS, local authorities and other local partners, each ICS incorporates an Integrated Care Board (ICB) and an Integrated Care Partnership (ICP). These bodies are jointly responsible for setting standards and strategic objectives as well as managing the resources and health needs of an area, or “system”, to improve the health of their defined population.
Impact on primary care
With the number of patient appointments at their highest rate since before the pandemic, urgent and emergency care under immense pressures and waiting lists for routine hospital care at an all-time high, effective collaboration across primary care and the wider health system has never been more vital. Realising the vision for integrating primary care could enable local systems to plan and organise coherent, urgent and emergency care services by developing care pathways within their communities.
Pressures on services and population health vary greatly between ICSs, as do the resources available. ICSs differ significantly in size and are at varying stages of maturity, which will affect how they collaborate and impact on local primary care services. With those general practices that are based in high areas of deprivation, tasks they and ICSs face will not be equitable.
The ICS-Design Framework outlines the minimum standards and expectations for ICSs and specifies that each ICB must have 10 mandatory members, one of whom must be from general practice. The value of primary care is appreciated in the framework, but further guidance is being sought on the level of accountability placed on primary care board members, and adequate resources are required to develop effective leadership capability and capacity.
How can Primary Care Networks support ICSs?
Each Primary Care Network (PCN) supports ICSs via clinical directors, providing a voice for primary care and formulating local plans in line with the NHS Long Term Plan and GP contract. PCNs provide opportunities for ICSs to engage with primary care and for integrated systems to hear what unique service and clinicians’ needs are, rather than imposing the ICS vision.
The ICS-Design Framework also emphasises the significance of provider collaboratives in facilitating ICSs. All NHS trusts are expected to be part of a collaborative; non-NHS organisations should also participate where this would benefit patients and make sense for the system and providers that are taking part. Provider collaboratives should enable the benefits of working at scale across multiple places/ICSs to improve efficiency, quality and outcomes; tackle health inequalities in access and experience across different providers; and foster greater resilience across systems to better support staff.
Potential for use of digital technology
Digital technology has the potential to meet community needs more effectively by transforming how people access service delivery and future care planning, and ICSs have a critical role in implementing digital transformation in primary care. To date, underlying infrastructure is often deficient, with widespread variation in digital maturity, knowledge and procurement across and within systems.
NHS Digital envisages GPs, practice staff, suppliers and buyers in ICSs, ICBs and commissioning support units collaborating to improve GP IT systems and services. In some ICSs, a chief information officer or chief clinical information officer has been appointed alongside named leads for primary care digital transformation. However, with millions of people living in areas that lack sufficient or affordable internet access, extra care must be taken not to expand digital inequalities.
ICSs face an uphill task with chronic staff shortages, services under extreme strain and health inequalities mounting. Analysis shows that there are fewer GPs per head in more deprived areas, and in rural areas recruiting and retaining staff is problematic.
Once established, the ICS work streams should be well positioned to explore wider solutions and consider population needs (eg education, transport), which differ for each ICS. This could help guide the recruitment of a more diverse and representative primary care workforce, incorporating local health inclusion groups to meet evolving needs and develop more effective health service.
Benefits for patients
Patients’ needs are becoming increasingly complex, and health and social care delivery must reflect this. One in three patients admitted to hospital as an emergency now has five or more health conditions — an increase from one in 10 a decade ago.
ICSs should lead to improvements in population health and patient experience, particularly those with complex and chronic long-term conditions and the elderly. Easier access to a wider range of diagnostic services (from basics such as phlebotomy to more in-depth diagnostics such as MRI and endoscopy) without the need to attend hospitals and proactive local care provision could help reduce pressures on the NHS and social care in the medium to long term.
Ongoing patient participation will be needed to gauge service improvement and understand how efforts to join up care are progressing.
What funding is available to support integration?
The National Network Investment and Impact Funds that support this work will increase from £75 million in 2020/21 to around £300 million in 2023/24; the GP contract stipulates this fund is to facilitate delivery of the NHS Long Term Plan.
A proportion of the fund will be used by PCNs in line with the NHS Long Term Plan’s “shared savings” scheme to reward practices for achievements such as cutting A&E attendances, emergency admissions and delayed hospital discharge in line with the GP contract. PCNs will need to agree with their ICS how the rest of these funds will be used. Whilst several ICSs across England have agreements enabling them to pool resources, NHS England states there is no requirement for PCNs to do so; however, they must consider how to work collaboratively within an ICS to deliver “the ICS’s overall strategic aims”.
The success of ICSs will be dependent on various factors such as resources, capabilities, governance/leadership, cultures and relationships. Additional workforce and resources will not miraculously address the immense challenges faced. The British Medical Association (BMA) supports efforts to improve collaboration both within the NHS and across the health and care sector, acknowledging potential value of greater integration but has expressed reservations around a single model of integration.
The revised system oversight framework from NHS England and the CQC’s new single-assessment framework, which will cover all sectors, local authorities and ICSs, reflect the changing landscape. An update to the NHS Long Term Plan is also due to be published this summer. NHS England will then launch a multi-year strategic-planning process with local systems, reflecting revised delivery expectations and incorporating a degree of local flexibility.
Evidence gleaned from previous attempts to integrate health and care indicate such change will take time, and local and national leaders need to make long-term commitments to properly embed this.
Integrated Care Systems Briefing, the BMA
Integrated Care Systems-Guidance Documents, NHS England
ICS-Design Framework, NHS England and NHS Improvement
GP IT Futures: Systems and Services, NHS Digital