ICSs take over in just six months, but many questions remain unanswered

How to create the right conditions, frameworks and incentives for local organisations to improve patient care is one of the most challenging and urgent questions for policymakers working in health. The Health and Care Bill will soon embed the latest in a long series of reform agendas, with integrated care systems (ICSs) being placed on a statutory footing from April 2022. With this deadline now just six months away, trust leaders and their system partners are busy translating national policy and upcoming legislation into real-world delivery.

The emerging policy and legislative framework that will determine how ICSs run is, encouragingly, permissive in its approach, with flexibility for local leaders to set up arrangements that make sense for their systems. There is however a lot of complexity and ambiguity for providers to work through, at an already demanding time.

Embedding system working amid significant operational pressures

The summer months saw a proliferation of ICS guidance, covering statutory integrated care boards (ICBs) and integrated care partnerships (ICPs), provider collaboratives and place-based partnerships. While these documents set out what systems are expected to deliver, they left a lot up to system partners to determine how it should be delivered locally.

At the same time, trusts have just come through "a summer that felt like winter", and now face the prospect of a challenging winter with a very tired workforce. Trust boards are focused on tackling care backlogs, managing complex risks and immediate challenges such as workforce shortages. While the new funding announced last month as part of the three-year NHS revenue settlement was welcome, it is accompanied by a challenging delivery ask and heavy sense of political – and public – expectation.

Setting up statutory ICSs raises some questions

Alongside this operational pressure, systems are focused on the transition of clinical commissioning groups to ICBs, as well as agreeing what funding and responsibilities will be delegated to provider collaboratives and place-based partnerships. They will also be busy getting the right people in post, with ICB chief executives appointed by mid-November, the rest of the ICB board by the end of the year and ICP chairs by February.

Relationships, relationships, relationships

Trusts' relationship with the ICB as strategic commissioner, funding channel and first line of oversight will be key. While some of the parameters will be set out in the national policy and legislative framework, it is increasingly clear that system dynamics will depend – as they so often do – on relationships, culture and behaviours.


Keeping a steady focus on improving outcomes is fundamental

Trust leaders are striving to help their systems remain focused on the overarching ambitions of system working – improving population health outcomes and access, tackling health inequalities and the wider determinants. They see significant potential in system working, but the complexity of setting up these arrangements risks distracting from the real task at hand. As the ICB board takes on performance oversight and funding allocation responsibilities, it will be more important than ever for systems to remain focused on their purpose.

Appropriate challenge will remain important

ICSs have been designed on the basis that system partners will agree priorities and how best to deliver them. The dynamics of system working may therefore run effectively, until something happens to disrupt them. If and when it does, there is a risk that the mechanisms for challenge and dispute resolution currently proposed may be insufficient.

For example, if a trust is given an impossible delivery ask within a constrained financial envelope, how will they challenge their allocation and to whom – the ICB or NHS England and NHS Improvement region? And, what will a clear line of accountability look like between ICBs and trusts? These are likely to become real-world issues for systems in the coming months.

The next normal

There are lots of known unknowns characterising this next phase of ICS development – how the funding will flow, how accountabilities will fit together, and what success will look like for local populations. Trusts and system partners need to be able to get on with the task at hand with the right support. And there need to be realistic expectations of ICSs so they are not set up to fail.

What is clear is that the NHS is being asked to reform at the same time as meeting a stretching delivery ask over the coming three years and addressing huge operational pressures in "the next normal", which will be characterised by tackling backlogs, meeting increased demand and living with COVID-19.  Collaboration in local systems will have to help trusts and their partners find new answers in challenging times.

This blog was first published by HSJ.