Taking Integrated Care Systems to the next level

Phil Hope of the Health Devolution Commission looks at emerging best practice approaches for Integrated Care Systems, including five key financial design principles that reflect collaboration rather than competition.

Integrated Care Systems are developing their unique purpose including shared outcomes, establishing new collaborative cultures, focusing on place-based ways of working, creating new governance and accountability structures, and designing new financial regimes.

These were the key messages heard loud and clear at the recent meeting of the Health Devolution Commission which heard from four Integrated Care Board chairs as well as the Chief Delivery Officer for NHS England and senior spokespersons from the Local Government Association and NHS Confederation.

The mood was upbeat and optimistic, with all those taking part in the meeting chaired by Andy Burnham and Norman Lamb feeling positive about the potential of Integrated Care Systems (ICSs) to herald a wholly new approach to our health and wellbeing as a nation despite a range of immediate challenges facing the NHS and social care. There was a strong sense that ICSs are genuinely transformational and a real confidence they have a high level of support among local and national leaders across all sectors. A full report of the meeting is available here.

Agreeing a set of shared outcomes is central to the new system and we heard from Naomi Eisenstadt, Chair of Northamptonshire ICS Board, that these may be best structured around a Life Stage approach of ‘Start Well, Stay Well, Age Well', that includes reducing local population health inequalities.  The focus on place being at the heart of the new system was emphasised, with ICSs aiming, over time, to maximise delegation of the ICS non-hospital spend to place-based partnerships responsible for delivering the agreed shared outcomes.

The Commission heard from Richard Douglas, Chair of South East London ICS Board about five key financial design principles within ICSs that reflect collaboration rather than competition as the new organising principle. ICSs would work best by seeking to remove financial disincentives to achieving its shared outcomes; create maximum funding certainty for providers; maximise financial delegation to providers and place boards; maximise flexibility in spending (but protect long-term prevention investment); and ensure full budgetary transparency.

The broad scope of the four primary aims of ICSs was warmly welcomed, particularly the emphasis on the NHS's role in supporting the broader social and economic development of the communities they serve. The importance of hospitals acting as anchor institutions in partnerships with others to help address population health inequalities in local areas was seen as vital. Richard Leese, Chair of the Greater Manchester ICS Board, felt the pandemic had shown that wealth and health are not in competition with each other, but in fact are mutually supporting - work and pay should be viewed as health outcomes.

The permissive nature of the legal framework for ICS was welcomed as providing opportunities for ‘desirable variation' in the way local areas organise themselves. The governance and accountability arrangements highlighted by Cathy Elliot, Chair of the West Yorkshire ICS Board, were clearly illustrated in a very useful ‘functions and decisions' map so all partners could see how they were involved in the system.

In SE London, the Integrated Care Partnership is seen as having the job of holding the Integrated Care board and other partners to account for delivering the IC strategy created by the partnership. It will do this by publicly assessing whether the Board's plan satisfies four key questions: does the plan reflect the integrated care strategy; is the plan financially viable; is the plan consistent with the commitment to reducing health inequalities; and does the plan reflect local population priorities? And there is a ‘stop the clock' mechanism to review and amend the plan if needed.

Whilst the mood was one of optimism, the Commission also heard that significant challenges remain to be addressed as ICSs become statutory bodies and implement their new ways of working. Pressure on the NHS to reduce the treatment backlog, social care chronic underfunding, significant workforce shortages, low pay and worsening national economic conditions will conspire to make the introduction of change that much harder.

And there are still many unresolved system issues requiring attention such as the role of Primary Care Networks in the system, the relationship between provider collaboratives and place-based partnerships, the behaviour of the regulators, the differing reward regimes for system leaders, and identifying what really works in ‘shifting the curve' on improving the public's health.

The Commission will play its part in highlighting best practice over the coming months. In June it will take an in-depth look at how ICSs can act to reduce health inequalities, improve the health and wellbeing of children and young people, and ensure the best services in mental health and for people with learning disabilities. If you would like to be invited to this meeting please email Director of the Health Devolution Commission

Phil Hope is a member of the Health Devolution Commission secretariat and a former minister for care services


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