Is the April 2021 deadline for ICSs to cover all of England too ambitious?
Providers will need to understand the criteria (as yet unpublished) for ICS status to understand the true impact of the 2021 deadline.
However, given that progress made to move to a model of system working will be vastly different from place to place, this deadline seems to us to be extremely ambitious. Some of the most advanced ICSs have been working on their transformation for many years and have had considerable time to develop critical relationships and address other issues. Yet in other areas, relationships between key partners do not exist and other issues may influence their ability to progress to an ICS, such as a lack of funding, lack of capital, workforce issues, the need to focus on recovering organisational or financial performance and more. All systems will require tailored support and investment to achieve ICS status by 2021 or beyond. It is vital that this support offer is designed collaboratively with those who it is designed to support.
What is the definition of an ICS and what criteria need to be satisfied for a health care system to progress to becoming an ICS?
The NHS England website begins its definition of ICSs with an introduction to STPs. It suggests that an ICS is a type of ‘even closer’ collaboration, going on to say that in an ICS “NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.”
This definition is very broad and places emphasis on the relationships within an ICS as a method to execute its mission of improving population health, but doesn’t delve any further the legal, financial or regulatory complexities of integration.
In order for these complexities to be addressed, and in order for providers to make further progress, further clarity from NHS England/Improvement is required on the criteria to achieve ICS status by April 2021. These criteria should be co created with local frontline leaders.
What functions should an ICS adopt?
Broadly, ICSs are a helpful forum for agreeing shared priorities and undertaking population health analysis. ICSs have the potential to share resource more effectively across a patch, so it may be that devolving workforce planning to an ICS could be effective. However, there are some functions that it may be difficult for an ICS to adopt due to conflicts of interest between partners, and in some cases, the geographical footprint of the ICS. The NHS has always operated on a series of footprints best suited to population need and the requirements to deliver services to different population sizes – for example, ambulance trusts and specialised services cover a number of STPs, whereas primary and community care are often more neighbourhood focused. It should be recognised that ICSs are a meaningful vehicle for collaboration and the provision of integrated, patient centre care and won’t always be the correct vehicle to deliver all government or arm’s-length body policy initiatives. It is therefore important for national and local NHS leaders to agree what functions should be delivered at each of neighbourhood, place, system, regional and national level.
Should there be an assurance process to assess whether STPs are ready to become ICSs and take more collective responsibility on behalf of the component organisations within their partnership? If so, what should that process comprise?
It is our view that peer review and self assessment should be an important component of the journey to becoming an ICS. This shouldn’t be a regulatory process but rather an iterative set of discussions between the STP and all local partners, and colleagues in the national bodies. This process needs collaborative design between national and local leaders.
How should the national bodies’ oversight role develop with regard to local systems?
The role of oversight from the national bodies with regard to local systems is still developing. The current legal framework applies to individual organisations, but we understand the direction of travel is to develop oversight mechanisms at a system level. These levels of oversight will need to complement each other, rather than implicate providers within multiple levels of scrutiny. CQC is not calling for powers to inspect and rate systems, but rather supporting systems to deliver on their objectives.
What forms of support should be put in place to support all systems to develop?
All systems will need support to develop into ICSs. This support should include technical analysis, for example, to assist with the analysis of population needs, the building of new infrastructure for the partnership, and crucially, on relationship building. NHS England/ Improvement have outlined their plans to create a development offer to support systems to undertake the required organisational development to deliver the plan, including assessing population health management maturity, creating a national learning network for health and care professionals and delivering an accelerator programme that provides support to a small number of STPs. We welcome this support and emphasise that all systems will require support to develop and that this support will need to be flexibly tailored to meet the needs of individual STPs.
How will ICSs work with providers that cross more than one STP/ICS or geographical footprint?
The STP or ICS isn’t an appropriate delivery mechanism for all policy initiatives, especially those which may not align with patient flow. Horizontal integration is more likely to take place across one or more STP or ICS footprints, or indeed between trusts in different STP and ICS footprints. In our view, it would be helpful for the national bodies to acknowledge these nuances more clearly.
How can we ensure key partners such as local government and primary care remain engaged in ICSs?
The success of STPs and ICSs will hinge on the ability of local partners including providers, local government and primary care, to work together. Both primary care and local government are central to the delivery of integrated care, but there is tension in some areas about the 'top down' nature of NHS policy and appropriate inclusion in its development. Many systems have adopted a local brand for system working which is more appealing to local partners and the public.