It's been a challenging first 12 months for fledgling integrated care systems (ICSs) which were placed on a statutory footing on 1 July last year.
With more challenges on the horizon, it's time to take stock of trusts' experiences as key budget holders and employers within those health and care systems, and central to driving the collaborative, population health focused change we all want to see.
The pace of change has been variable according to trust leaders. For many real focus on some of the ambitions of ICSs – to improve outcomes in population health, tackle inequalities and help the NHS support broader social and economic development – feels a long way off. Integrated care boards (ICBs) have understandably been occupied with establishment issues, system governance and the huge organisational and structural change required to make the transition to this new way of working.
Despite welcome efforts by NHS England to clarify roles and responsibilities, trusts still tell us that greater clarity about the role of ICBs is needed.Chief Executive
These challenges have been compounded by sustained, severe pressures facing the whole health and care system. Energy spent on operational 'fire fighting' – on waiting lists, urgent care and industrial action – has reduced leadership capacity to lay the groundwork for serious improvement on population health and inequalities. Year two of ICSs is likely to see more of the same.
While many trust leaders have seen a real evolution in relationships over the last year, and statutory system working has given collaboration greater impetus and credibility, this isn't universal yet and will take time to build. We still hear that old patterns of 'commissioning' behaviour and contractual or transactional approaches continue in some systems.
And with a target to deliver a 30% reduction in ICB running costs by 2025/26 there is a clear risk that ICBs' focus will be diverted.
Effective system working is underpinned by strong relationships and consistent collaboration. This requires buy-in at every level of each organisation, and for many partners – including trusts – a profound cultural shift. Working with partners is something I had a positive experience of in my former role as a trust leader.
Despite welcome efforts by NHS England to clarify roles and responsibilities, trusts still tell us that greater clarity about the role of ICBs is needed. Expecting ICBs to be both a convenor and performance manager of their system is an uncomfortable fit for many and stretches already-limited capacity. An additional tier of management and regulation will add little value: trust leaders want to work with ICBs as equal partners in pursuit of shared goals, and are keen to see far greater focus on trust and system level improvement approaches instead of top down performance management.
For some systems, provider collaboratives have played a key role in managing operational pressures such as reducing elective waiting lists and cutting delayed discharges.Chief Executive
Trust leaders are particularly positive about the work taking place through provider collaboratives and place-based partnerships even where they report challenges in their systems. In some cases they are flourishing even where the ICB is severely challenged, demonstrating the leadership that trust leaders bring to every level of system working.
Provider collaboratives at scale or at place are developing to serve communities and join up services, delivering benefits such as reducing waste, managing workforce capacity and improving quality of care. For some systems, provider collaboratives have played a key role in managing operational pressures such as reducing elective waiting lists and cutting delayed discharges.
Local authorities too have essential expertise in tackling the wider determinants of health and health inequalities and are key to unlocking the potential of ICSs. At a 'place' level and in the day-to-day delivery of services, local authority and NHS colleagues are working ever more closely together which is something we need to see more of. And at the strategic level, integrated care plans have now been submitted by systems.
While this does not overcome challenges relating to different NHS and local authority funding and accountability structures, it is an important first step in creating a shared vision for wider services within the scope of ICSs. It is not clear yet whether these plans will lead to progress in collaborating towards shared goals of preventing ill health and reducing inequalities, but they are necessary to begin that work.
So, what are the next steps? Big cultural shifts and organisational changes take time but there are some key enablers to support the next phase of ICSs. It is clear that further structural change would be damaging to the health and care system, making it all the more important to support ICSs to succeed in a challenging environment to deliver for populations.
With a concerted effort, the longer-term ambitions of system working are within reach.Chief Executive
First, greater clarity about the roles and responsibilities at every level of system working will help leaders to focus on the long-term. For instance, ICBs' energies will best be spent not on quasi-regulatory activity, but on strategy and brokering relationships within systems to add real value to collective ambitions to improve population health.
Likewise, a balance between central control and system level autonomy is important, including through a slimmed down set of national targets (as recommended by Patricia Hewitt's review of ICSs), aligned financial incentives which don't pull against collaboration in times of pressure making good on the more mature behaviours set out in NHS England's operating framework. There remains a strong role for regional teams in bridging these gaps.
Looking ahead, with a slimmed down ICB on the horizon through cuts to running costs, place-based partnerships and provider collaboratives will have an essential role in delivering on the core ambitions of ICSs. There is already significant optimism here, and with further time and space to navigate new relationships, governance structures and financial arrangements, the potential is huge.
With a concerted effort, the longer-term ambitions of system working are within reach. Trusts are ready to play their part as equal partners in systems.
This opinion piece was first published by HSJ.