A step change in system working but big questions remain

Georgia Butterworth profile picture

27 November 2020

Georgia Butterworth
Policy Advisor


Today NHS England and Improvement signalled a significant step change in the evolution of system working. There is now a clear national plan to accelerate the development of integrated care systems (ICSs) in 2021/22, which anticipates legislative change aimed at underpinning those developments from April 2022 and better supporting the aims of system working to improve outcomes and reduce health inequalities.

In a world of great uncertainty – the novel COVID-19 virus, the outcome of Brexit negotiations and the wider socioeconomic context to name but a few – this paper offers a welcome translation of what NHS England and Improvement previously described as a 'system by default' approach into some potential practical arrangements on the ground.

Our briefing summarises the content of the paper, which includes a whole new raft of roles and responsibilities for ICSs themselves, as well as minimum standards that provider collaboratives at ICS and place level will need to meet.

Many of these proposals are welcome. First, the paper emphasises the key leadership role that providers play at ICS and place level. This reflects the learning from how collaboration between providers proved to be the engine room of the COVID-19 response.

Second, trust leaders support place as the key building block for integrating health and care services, as this is where 80% of care is delivered to local populations. NHS England and Improvement has codified a national 'offer' at place level but allowed local systems to determine the scope and scale of their place-based partnerships.

Trust leaders support place as the key building block for integrating health and care services, as this is where 80% of care is delivered to local populations.

Georgia Butterworth    Policy Advisor

These proposals will no doubt raise lots of questions about implementation, but we welcome NHS England and Improvement's recognition that there is no 'one size fits all' to provider collaboration and will examine whether the minimum standards they set out are fit for purpose.

Third, cementing the move away from transactional contracting and towards strategic commissioning at ICS level will be widely welcomed in support of a more collaborative and effective approach to population health management, improving outcomes and reducing health inequalities. Within this – with sufficient resource – providers are keen to take on a greater role in service transformation and pathway redesign.

So are there any areas to probe? Given the detail in the proposals, we'll need some time to work through what the operational impacts look like in practice. But at first glance, what is asked of ICSs and their component organisations in 2021/22 and beyond feels like it could be very complex.

The paper maps out the existence of providers, provider collaboratives, neighbourhoods, place-based partnerships, ICSs and NHS England and Improvement regions, with leadership arrangements at all levels. This will require clear, effective and non-duplicative "plumbing and wiring" in areas such as governance, accountabilities, financial flows and statutory responsibilities.

We will also need to marry the top down proposed accountability structure with the bottom up realities of delivering healthcare on the ground. The national policy and legislative framework will need to embrace this complexity.

The policy developments in this document are framed as helping the NHS to become a better partner for local authorities, which is a shift in the narrative of ICSs being jointly owned by the NHS and local government. This could seem at odds with the welcome focus on prevention and population health management. Without councils' full involvement, how will ICSs achieve their ambitions to improve population health and tackle health inequalities?

And as for an NHS Bill next year?

Significant legislative change for the NHS is still on the horizon. It seems likely that this will be the single chance for NHS legislation this parliament – perhaps even this decade – and we are therefore expecting an omnibus Bill in late spring 2021 covering a range of different areas.

While we expect NHS England and Improvement's legislative proposals, developed and agreed with the health and care sector last year, to largely remain on the table, we now know that the government and national NHS bodies are considering more radical options for putting ICSs on a statutory basis than previously envisaged.

In the recently published policy paper, NHS England and Improvement has proposed two new options for putting ICSs on a fuller statutory footing – either a mandatory ICS board/joint committee or a corporate NHS body model that brings clinical commissioning group functions into the ICS. Both these options represent a significant shift from NHS England and Improvement supporting ICSs as coalitions of the willing to effectively a new strategic commissioner working 'in partnership' with providers.

Trust leaders have a range of views about whether, and to what extent, ICSs should be placed on a statutory footing, which we will explore fully in our consultation response to NHS England and Improvement.

Georgia Butterworth    Policy Advisor

Trust leaders have a range of views about whether, and to what extent, ICSs should be placed on a statutory footing, which we will explore fully in our consultation response to NHS England and Improvement. We do know one thing – trust leaders and partners from across the health and care system agree with NHS England and Improvement on the need to avoid another top-down re-organisation of the NHS.

So while the paper sets a clearer strategic direction for the interim period of 2021/22, in doing so it raises a whole host of important and detailed questions. We must therefore have a rigorous debate and true, meaningful engagement over the next month, to learn from 2012 and avoid legislation which creates more problems than it solves.

This blog was first published by the National Health Executive.

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