The American industrialist Henry Ford once said: ‘Coming together is a beginning, keeping together is progress, working together is success.'
When Integrated Care Systems (ICSs) were created, it was hoped the NHS and local government would embody that principle. The idea was simple but ambitious: build trust, share responsibility and deliver better outcomes for patients and the public by working hand in glove.
Yet, since the outset, that goal has proven elusive. Current financial pressures have forced both those in local government and in the health service into reorganisations, consolidations and cost reductions – with a heavy dose of uncertainty to boot.
Integrated Care Boards (ICBs) have been charged with slashing their running costs by 50%: an ill-considered imperative that has triggered months of upheaval, a process mired in complications and ambiguity and with it, the inevitable leadership churn.
Local government, itself also stuck in reorganisation mode, is trying to grapple with a broken social care system that successive governments have avoided reforming.
The cracks were there at the beginning. Now they are widening into crevices. Leaders across public services are no rookies to the narrative. They pursue integration to deliver more joined up-services for the public and improve productivity and efficiency. Then financial pressures increase for reasons outside of their control and leaders often understandably retreat into silos to mitigate financial risks and get through until financial year-end.
Those of us who have been around long enough will have seen this cycle repeat many times over. How do we put an end to it?
Surprisingly, given this bleak backdrop, there are glimmers of hope. The founding vision of ICSs still casts a light, often built on good practice and relations, years in the making. Recent conversations between NHS and local government leaders, supported by the NHS Confederation and the Local Government Association, have served to highlight some practical steps to success.
Firstly, joint planning and commissioning is key – supported by a strategic commissioning framework that actively encourages collaboration with local government.
Secondly, financial transparency and shared responsibility, including early engagement and open communication, can help prevent partners being pitted against one another.
Finally, payment reform that incentivises more preventative, community-based models of care are vital, backed by seed funding to kick-start change.
In Rochdale, Leeds and Sunderland, to name a few, there are positive examples of joint commissioning teams and pooled budgets that provide better outcomes for patients, more opportunities for staff and better value for money.
Elsewhere, collaboration between Walsall Healthcare NHS Trust and Walsall Council – backed by a comprehensive section 75 agreement and involving the co-location of teams and shared accountability lines across the NHS and local government – is enabling partners to get more for their population with the same funding. That includes improvements to delayed transfers of care, fewer hospital admissions and faster handovers at A&E.
And in North Central London ICB, as well as in Lancashire and South Cumbria ICB, there are lessons to be learned in how integration can not only withstand financial strains, but help to mitigate them.
The system is awash with pockets of good practice like these. What is needed is for national leadership to double down on integration as part of the solution – not a distant ambition to be achieved once we have our houses in order.
While the Government's 10-Year Health Plan rightly insists on financial discipline, phasing out deficit funding and requiring providers to break even, without structural reform this policy risks becoming austerity by stealth.
The result? Local leaders left managing the fallout, lacking the agency or funds to do more than tinker around the edges of change in their localities.
Although the NHS emerged as a relative ‘winner' in the Government's last Spending Review compared with other public services, this win, most of which was consumed by pay increases and barely keeping pace with patient demand, has felt bittersweet.
While the Government's much-awaited Casey Commission offers an opportunity to confront these challenges head-on, it will only do so if minsters are willing to make brave decisions and take the public on a journey to accept the choices we must make.
The promise of ICSs was about creating a system that works for people, especially the ever-growing numbers of people with complex conditions and needs. That promise is now at risk.
Without urgent reform of social care and a more honest conversation about the financial realities facing both the NHS and local government, integration will remain merely an aspiration.
Matthew Taylor is the chief executive of the NHS Confederation
