Context and operational pressures

In the past year, the NHS has made important progress in a challenging operational landscape. It has virtually eliminated 104-week waits and is exceeding pre-pandemic levels of activity in crucial areas such as two-week referrals for suspected cancer pathways.

However, the operational pressures, particularly around care backlogs, patient flow, and demand for urgent care, have been huge. And as we now enter winter, economic pressures, the increased cost of living, and activity driven by Covid-19 and flu cases, are likely to exacerbate these challenges and impact on both staff and service delivery.

These pressures are being felt across the NHS, in acute, mental health, community, and ambulance services, and are made more difficult by staff shortages in the NHS, which, at the time of writing, stand at 132,000.

Trust leaders see system working as part of the solution. No single organisation can effectively address longstanding challenges like staff shortages, health and race inequalities, and growing demand for services, alone.

Trust leaders have therefore made it a priority to support the setting up of ICSs, and to drive forward improvement through partnership working. They understand that collaboration between system partners can help address immediate pressures and deliver longer term improvements to quality of care and service delivery.


The trust contribution to system working

In July 2022, the Health and Care Act came into law providing a legal basis for collaboration between NHS bodies and to facilitate integration. This cemented a wider shift towards collaboration and integration, and was the logical next step as most trusts have been moving in this direction for some time.

ICSs are being established through statutory integrated care boards (ICBs) and integrated care partnerships (ICPs), and much of their business will be conducted through place-based partnerships and provider collaboratives. Trusts will be key players in this new context at the sharp end of delivering care, reducing care backlogs and driving transformation in a new system context through new collaborations. Trusts legal underpinning is unchanged by the recent Act, they will deliver many local services for patients, and remain the main employer of NHS staff.

As such, trusts will be a key player in delivering the four key priorities of ICSs: improving outcomes in population health and healthcare; tackling inequalities in outcomes, experience and access to healthcare; boosting productivity and value for money; and supporting broader economic and social development in local communities.

Alongside these opportunities, there will be a need for system partners to manage new risks. For instance, oversight from ICBs must add value, and avoid creating extra complexity or burden for trusts. Conflicts of interest will emerge and will need to be managed. And, in the face of different delivery structures, there must be clear lines of accountability for operational and financial performance, and quality of care.


Local response to a national shift

One size does not fit all. The opportunities for, and approaches to, collaboration look different depending on local circumstances.

This is evident from the case studies of good practice highlighted in this report. It demonstrates that there is impressive and varied work taking place to drive forward improvements in care for the benefit of patients and service users in different ways within a system context.


Working across sectors to address health inequalities

The North West Ambulance Service NHS Trust have been using the hypertension data collected by ambulance teams to support interventions targeted at reducing health inequalities and preventing ill-health. To do this, they worked closely with local primary care partners to share relevant data for high-risk groups.


Convening a range of partners to support cancer care and mental health services

The Clatterbridge Cancer Centre NHS Foundation Trust have been working alongside urgent care and cancer care partners as part of the Cheshire and Merseyside urgent cancer care board. The group brings together these partners, and other key stakeholders, to support appropriate and timely urgent care close to home with the goal of improving quality of care and patient experience.

Avon and Wiltshire Mental Health Partnership NHS Foundation Trust have been running a system-wide mental health finance oversight group covering both ICSs in which they operate. This forum brings together a range of key partners from across the NHS, local authorities and the third sector to explore how they are spending mental health money as a system, and where there is potential for improved efficiency, additional investment, and reduced variation in service delivery.


Collaborating across systems to support admission avoidance and timely discharge

Central London Community Healthcare NHS Trust have been collaborating across systems to deliver two different models of virtual wards that support admission avoidance and timely hospital discharges. At the centre of both models is a focus on tackling health inequalities and digital exclusion.


Supporting staff and the wider system to address elective backlogs

Maidstone and Tunbridge Wells NHS Trust have eliminated 52-week waits for elective care, enabling them to support neighbouring trusts to address backlogs. A focus on staff wellbeing and a clinically led model of delivery, which affords frontline staff greater control over strategic decisions, has been central to the effective recovery efforts at the trust.


A continuing journey

We are at an early stage in the journey of ICSs, and it will take time for them to be fully embedded and demonstrate added value.

But trusts are already driving new opportunities as system partners to change how they work with each other and wider partners. At the heart of this, there is a commitment to improving care for patients and service users.

Trust leaders are keenly aware of the opportunities of system working, as demonstrated by the case studies in this report. With the right support and resource, trusts will continue to play a critical role in unlocking the benefits of this new landscape.