It is encouraging that these common features are starting to emerge as they will help us to identify how to support STPs and ICSs to mature at pace.  As the NHS gears up for a new and ambitious ten-year vision, underpinned by a five year delivery plan, we have reached an inflection point politically and in terms of the development of system working. It would therefore be helpful to consider the following questions, in partnership with the national bodies and other stakeholders as we work out the future shape and role of STPs and ICSs.


What is the desired function of STPs?

We would welcome a more transparent debate about the desired 'end state' for STPs, and ICSs and the more granular processes of allocating responsibilities to STPs, individually and collectively particularly given their status as non statutory partnerships, resting on the voluntary commitment of their respective partners. We are concerned that at the moment the national bodies are delegating important functions like capital prioritisation and estates and IT planning to STPs without leading an open and transparent debate about the role and function of STPs and without checking the capability of individual STPs to fulfil those responsibilities.

Is it accurate to describe all STPs as moving towards becoming ICSs or should the national bodies, and the sector, distinguish more precisely between the features of an STP and an ICS? 

  • The refreshed planning guidance set out an expectation that all STPs will develop to become ICSs that exercise greater local autonomy and are capable of taking on a wider range of responsibilities. But on 49% of trusts in our recent financial planning survey agreed that ICSs should replace STPs. We fully support the existing, and aspirant, ICSs but we would also welcome more recognition from the centre that this direction of travel may not be workable for all STPs.
  • STPs and ICSs also cover a range of population sizes ranging from several hundred thousand to around 3 million. We understand that the national bodies intend future ICSs to be mapped onto an existing STP footprint (rather than covering a sub system within a wider STP as a couple of the current ICSs do). However the range in population sizes still raises interesting questions about which levels of ‘system’ working will adopt neighbourhood, 'place' or ICS responsibilities, as we have set out above.  In some STP footprints the relevant CCGs, providers and local authorities are acting on the basis that the STP is unlikely to work, and placing their energies at the level of more local, place based system working on smaller footprints.
  • We are pleased to be working with NHS England/ NHS Improvement and partners including the Local Government Association, NHS Clinical Commissioners and the NHS Confederation to develop a joint offer of support for STPs, particularly those struggling to get off the ground. However we would also welcome a conversation with the national bodies about how best to support those STPs which will either never be sufficiently mature to become ICSs or will take a long time to get there.  For example: should challenged STPs be supported to become more effective as quickly as possible because various key responsibilities will be consistently delegated to the STP footprint level and, if STPs fail to develop, their local system will lose out? Or should national system leaders accept that it is up to local systems to decide how much and what local STPs want to undertake at STP level and be very wary of consistently delegating important responsibilities to STPs?



How far is the development of STPs reshaping the national architecture? Are we happy to accept a degree of diversity in delivery mechanisms within the national system?

  • How will NHSE/NHSI’s new joint regional structure, which seeks to create a strong regional interface between national bodies and local systems and institutions, impact on STPs and ICSs?

The new 'empowered' regions are designed to be significant sources of influence and direction, with considerable delegated responsibilities.  It will therefore be important for NHS England and NHS Improvement to work with STPs/ICSs and local organisations to avoid creating too many bureaucratic tiers of activity.


  • What is the relationship between STPs, ICSs and commissioning?

The national bodies need a manageable administrative infrastructure through which to oversee the system as a whole, hence the move to create 44 STPs as a 'layer' between national and local bodies.  However, within this a diversity of approaches is emerging including ICSs, two devolution areas, a range of local approaches to explore closer collaboration with commissioners, and alternative payment options to the tariff.


  • What are the implications for regulation and oversight?

The role of the regulators is evolving with NHSI seeking to focus on improvement, the CQC developing its approach to system and ICS reviews, and NHS England and NHS Improvement seeking to work more closely together particularly at a regional level.  Feedback from our survey programme shows trusts feel the regulators need to go further to adapt their approaches to keep pace with system working.


Should we challenge the assumption that all STPs become the primary vehicle for system performance management given that accountability sits with individual organisations?

We want to support those trusts effectively engaged with partners in managing performance collectively within their local system but we are conscious that the STP will not always be the best route for improving sustainability or performance. Crucially, legally accountability sits squarely with individual organisations, notably providers and commissioners, so we should guard against a blanket expectation for all STPs to take on this responsibility as it may set some up to fail.


Are we happy to accept that the NHS and care sector has always operated on different footprints and will continue to do so? 

The STP isn’t an appropriate delivery mechanism for all policy initiatives which may not align with patient flow, historical relationships or clinical need.  Our view is that vertical integration is much more likely to develop around concepts of 'place' or 'neighbourhood' perhaps building on the work of vanguards or other initiatives within an ICS or an STP. In contrast, horizontal integration (of back office or some clinical services including specialised services) is much more likely to take place across one or more STP footprints, or indeed between trusts in different STP footprints. In our view, it would be helpful for the national bodies to articulate these nuances much more clearly.


How can we ensure key partners such as local government and primary care remain engaged in STPs?

Feedback from different local government sources reflects disappointment from many councils about the 'top down' nature of NHS policy.  Primary care is central to the Five year forward view but struggles to engage at scale within STPs. Many systems managing to engage with key stakeholders have adopted local branding for their partnership. 



Are we pushing the bounds of the 2012 Act too far? 

The leadership of NHSE has been open about shifting the policy focus towards collaboration and away from competition, the spirit of the 2012 Act. Trusts and their partners can collaborate voluntarily within the current legislative framework but this does make for a complex environment to navigate, not least to ensure clear lines of accountability. While much of this change is welcome, it raises legitimate questions about accountability, consultation and scrutiny at national levels, and sometimes for local partners.



Are STPs and ICSs a long term game?  

It seems likely that at some point in the future, a change of political leadership, and/or eventual legislative change will alter NHS structures once again. However, although the opposition may not have supported STPs they have long championed integrated, and person centred care, and are in favour of public sector collaboration over competition. It therefore seems unlikely at this point that the investment trusts and their partners are making in STPs and ICSs –to collaborate and integrate care - will go to waste.