The first year of statutory system working has brought challenges and opportunities but trust leaders are playing a full role as the co-leaders of their local systems and driving forward the core ambitions of integrated care systems (ICSs) – to improve outcomes in population health, tackle inequalities and help the NHS support broader social and economic development.
One way trusts are providing leadership in their systems is by using their unique expertise and insight as integrated care board (ICB) trust partner members.
Directors of trusts are nominated to be a partner member by local NHS trusts and foundation trusts; a final decision on whether to approve the appointment is then made by the ICB chair. On appointment, a trust partner member retains their trust role, meaning they hold positions in both their organisation and ICB.
Trust partner members, who are often trust chief executives, sit on the ICB to represent the interests of the system, rather than, for example their organisation or the provider sector specifically. However these roles do allow for perspectives and experience from within a provider to sit at the heart of system planning and commissioning. This is positive but requires a significant shift in mindset for the individuals occupying these roles, as well as fellow ICB board members and colleagues across the system.
In fact, this position is unconventional in corporate governance terms. As such it creates new, and still contested, questions about the ideal composition of the ICB board, the scope and accountabilities of partner member roles, and the management of conflicts of interest.
Trust partner members occupy a distinctive position on ICB boards. Understanding their experiences gives a crucial insight into how system working is progressing, and how ICBs are functioning as well as helping to ensure these posts support systems and ICBs to function as effectively as possible.
Between July and September 2023 we spoke to around 10 ICB trust partner members from across England about their reflections on the last year in post. The trust partner members we spoke to were chief executives based in acute, mental health or mental health and community providers.
As with any issue related to system working, progress and experiences are varied. However, there are some common themes and clear learnings from those we spoke to.
Getting the composition of the ICB board right
The level of provider representation on ICBs is varied, and there are unresolved concerns about the voice of mental health and community providers
The Health and Care Act 2022 requires that, at a minimum, there must be three partner members, drawn from: an NHS trust or foundation trust; primary care; and a local authority. NHS England (NHSE) guidance also states that one of the 'ordinary members' of the ICB, which includes trust partner members, should have 'knowledge and experience in connection with services relating to the prevention, diagnosis and treatment of mental illness'.
Outside of these minimum requirements, there is a high degree of flexibility and local autonomy over the composition of the board. While this locally-driven approach is welcome, it means provider representation on ICBs is varied. Some boards will have just one trust partner member from the NHS, while others will have a larger number from across different sectors of the NHS. Ultimately, ICBs need to strike a balance between ensuring appropriate voice and input from a range of key partners from across the health and care system and keeping the unitary board a manageable size and balanced between executive and non-executive directors.
Some trust partner members describe the benefits of having all sectors represented on the ICB. This is viewed as helping to create parity of esteem between acute, community, ambulance and mental health providers. But this approach is not universal: some ICBs have opted to have just one trust partner member, in line with the minimum requirement. While this helps prevent the ICB becoming unmanageably large, some express concerns that it does not deliver sufficiently wide-ranging provider expertise on boards.
As described above, one of the 'ordinary members' of the ICB must have knowledge and experience of mental health services. This person can be drawn from within or outside of the NHS, and trust partner members appreciate the value that those from outside of the NHS, particularly those from the voluntary sector, bring to the ICB. However, some suggest that mental health trusts occupy a distinct space in their systems and should be required to sit separately on the ICB as a trust partner member.
When the ICB member representing the mental health perspective is a partner member from a combined mental health and community trust, some have raised questions about the extent to which they are able to draw on the full breadth of their wider expertise and experience. It can be particularly challenging where there are no other community provider delegates on the ICB.
Despite the steer in the Health and Care Act 2022, and in guidance, there remains confusion and debate about how far these roles could or should be representative of provider views in practice. This is a particular concern for mental health and community providers who are keen that their experiences directly inform the work of the ICB.
Scope of the partner member role and accountabilities
As representatives of the wider system (and not their organisation), ICB trust partner members occupy a new and complex space for NHS leaders, that is not always well understood by key system partners
The transition in mindset from being accountable for an organisation to representing the interests of the wider system is a real departure. At present, wider structures and incentives do not always align with this new approach. For example, targets around elective recovery are currently aligned to the performance of individual organisations rather than systems. We also heard examples of some ICB board members continuing to put organisational or sectoral interests ahead of those of the system.
The NHSE guidance states partner members can bring, 'knowledge and a perspective from their sectors, but do not act as delegates of those sectors', but this is not always well understood. There are inherent tensions in fulfilling the role, which national guidance does not resolve.
For trust partner members, this can create additional pressures, with some reporting that provider colleagues expect them to 'get results' from the ICB on sector-specific issues or conversely a misinterpretation of the role from ICB colleagues that they would be accountable for, or performance managing, other NHS organisations on the patch.
Linked to this, there is a lack of clarity about the extent to which trust partner members should consult with and canvass the views of provider colleagues. NHSE guidance emphasises the benefits of trust partner members engaging with 'other significant providers', and many partner members report summarising and sharing ICB papers to gather feedback from colleagues ahead of meetings. But this can reinforce misconceptions about the scope of the role. Trust partner members note this type of engagement is only made possible by receiving timely and digestible documents from the ICB which does not always happen.
Trust partner members also say that ICB chairs have a role in building a clear understanding of the responsibilities and remit of a trust partner member. Some trust partner members praised the disciplined chairing of ICB meetings, which helps input to remain focused on the wider system perspective. Setting expectations from the outset, especially for new members of the ICB, can also play an essential role in ensuring all members are clear about the parameters of their role. However, not all ICB chairs have the same level of experience and understanding, and some partner members reported a less robust approach to chairing meetings and less confidence in managing the complex dynamics at play.
Conflicts of interest
There is scope to improve the way conflicts of interests are managed to ensure action is proportionate to the risks, to enable trust partner members to contribute effectively
On the whole, the duties of trust directors should be aligned to those of ICBs, but it is possible for these duties to come into conflict. In June 2023, NHS Providers commissioned McDermott Will & Emery UK LLP to produce guidance to support trust partner members with this.
Trust partner members did report experiencing potential conflicts of interest, for example where an organisation would benefit from ICB investment. They described reporting these interests and agreeing the limits of their involvement within the fact finding and decision-making processes.
In some of these cases, we also heard about disagreements around what constitutes a conflict of interest and how these should be handled to protect the integrity of the ICB’s decision making process and uphold partner members’ director duties. These issues are often complex. We heard some concerns around whether decisions had been handled proportionately: for example some trust partner members reported instances of being asked to leave a public meeting with no advance warning because of a potential conflict of interest.
The NHSE constitutional guidance states that it should not be assumed trust partner members are personally or professionally conflicted by virtue of being an employee, director, partner or otherwise holding a position with one of these organisations. However, some trust partner members say this approach is not being upheld. In some cases, exclusion from the discussions has been deemed as unnecessary by trust partner members, and limited their capacity to contribute a provider perspective in decision-making.
There are also unresolved questions about how conflicts of interests are managed when trust partner members return to their provider organisation’s board after an ICB discussion. They may be party to confidential information from the ICB, for instance around commissioning intentions. Even if this is not shared with their organisation’s board, the individual will still be aware of this information.
As the functions and mechanics of system working develop, challenges around conflicts of interest are likely to increase. ICBs will move out of the establishment phase, and are likely to take bolder decisions around the use of resources. Likewise, formal delegations of ICB budgets or functions will generate new questions about who can be involved in decision-making processes, for instance through joint committees. Transparency and early discussion between ICB members about what interests need to be registered, what constitutes a material interest, and what action will be taken, are all key to navigating some of these challenges and supporting ICBs and trust partner members.
Trust partner members play an important role in navigating the challenges facing ICSs and driving the ambitions of system working forward. They also ensure that an NHS provider voice and leadership is at the centre of ICB decision making.
However, the role is challenging and complex, and the new space it occupies certainly creates stubborn questions around provider representation on ICBs, the role and accountabilities of trust partner members, and how conflicts of interests are managed in a fair and proportionate way. There are no easy answers to these challenges, and it is fair to say that these issues are built into the role as it is designed in support of a move away from a clean commissioner/provider split to system arrangements intended to be more collaborative.
Many of these issues will need to be addressed at a local level and may well be supported by more time, greater experience of system working, and the ability to discuss some of these issues at the ICB and trust board meetings. But national policymakers have a role to play as well. They too must take the opportunity to understand how ICB boards are functioning in order to better understand the progress and mechanics of system working. It is possible to learn from the early insights of trust partner members and use this, not only to support them in post, but to develop and evolve this landscape to ensure that systems can deliver on their key priorities.