This year, we have found ourselves at a critical juncture for system working. ICSs were put on a legal footing in July 2022, and the journey towards greater health and care integration has moved into a new phase of development.

As this report shows, NHS trusts and foundation trusts are at the centre of this [journey]. They have been acting as the engines of transformation, using their distinctive position to drive forward and steer the development of system working for the benefit of the communities they serve.

And trust leaders have been putting great energy and commitment into progressing the ambitions of system working. This is no small feat considering the many other operational and strategic challenges they face. But the prize is clear; collaboration brings with it significant benefits and opportunities to deliver better care for patients and service users.

At this stage, ICSs are operating in various forms and across different footprints. Local determination is at the core of system working, and we can see this play out successfully in the case studies included in this report.

While one size evidently does not fit all, there are some important thematic learnings to take from trusts delivering on some of the key priorities for ICSs.

Developing good relationships with partners is key to improving service delivery for the benefit of patients. The Clatterbridge Cancer Centre NHS Foundation Trust have developed strategic and operational relationships between urgent care and cancer care, while Avon and Wiltshire Mental Health Partnership NHS Trust have built trust between system partners enabling transparent and open conversations about funding across systems. In several examples, trust leaders say relationships and partnerships prompted by Covid-19 have laid the groundwork for deeper collaboration.

Collaboration can also help to drive forward the health inequalities agenda, which is a core ambition of system working. North West Ambulance Service NHS Trust have worked closely with primary care colleagues to share data across the sectors, enabling more targeted preventative interventions. Central London Community Healthcare NHS Trust and their acute partners worked together to expand the delivery of virtual wards, which has helped to reduce length of stay and avoidable hospital admissions, while also keeping a clear focus on tackling health inequalities.

Initiatives to support staff are also central to delivering on the priorities for systems. Maidstone and Tunbridge Wells NHS Trust ascribe their effectiveness in meeting elective recovery targets to the prioritisation of staff wellbeing and the promotion of a clinically led approach to recovery. In turn, this allowed the trust to support long waiters from neighbouring trusts, and work collaboratively to tackle system level challenges around health inequalities.

There is further to go in implementing and embedding system working given the extent of operational pressures, and given that ICSs come from different starting points, covering different levels of deprivation and different geographical footprints. There are also unresolved questions to iron out as systems develop and mature, to sustain good governance and clear lines of accountability.

Government and national support is still needed in support of ICSs and their health and care partners. This means boosting the recruitment and retention of staff with a long-term, fully funded, national workforce plan; securing enough capital investment; cross-departmental action to prevent ill-health and support people to lead healthy, independent lives and government action to place social care on a sustainable footing.

However, the work detailed in these case studies shows there is cause to be optimistic about the impact of system working. Trusts and their partners are already effectively rolling out new cross-sector ways of working, and are committed to driving forward the ambitions of ICSs. This will be key to ensuring the whole health and care system delivers first-class care.