Integrated care – a progress report

Principal consultant Aidan Rave assesses the progress made by integrated care boards since their inception two years ago and highlights some of the challenges ahead

As we mark the second anniversary of the creation of integrated care boards, it’s worth pausing to reflect on the progress they have made over the last couple of years, as well as the many challenges they must still overcome.

Let’s be clear: it was a pretty tough baptism for the ICBs. Launched just as the sheer scale of the post-Covid demand recovery was becoming clear, they seem to have been clinging onto the coattails of events ever since. Between 2020 and 2024, the number of people awaiting elective care ballooned from around 4 million to more than 7.5 million, and many of those people are now in the unacceptable position of having waited in excess of a year for their care.

In the face of these huge challenges, it’s worth reflecting on what is being done as well as what isn’t. The NHS still interacts with around 1.3million people every single day; it manages to run an operation with a budget that dwarfs that of many small countries and, as we saw vividly during Covid, when it needs to step up, it generally does.

The only way is up

In terms of demand, however, the numbers are inexorable, and they are only heading in one direction. The ability to continue to meet the scale and complexity of the demand facing the sector is impossibly beyond the capacity to meet it and ICBs were created, at least in part, to provide a strategic vehicle to begin to address this challenge.

Given that only 20% of an individual’s health prospects are determined by clinical factors, it makes perfect sense to create a collaborative governing structure that can identify and proactively address the social, economic and environmental factors that so heavily influence health outcomes.

To have leadership from public and voluntary sector organisations dealing with housing, communities, education, troubled families and many other interventions sat around the same table offers the prospect of tailoring interventions, getting ahead of the curve and, in time, guiding people away from the ever-growing queue for acute care.

Relationship management

So, if the model is right, what’s wrong?

The fundamental challenge still facing ICBs and the care systems they are part of, is the relative immaturity of the senior-level relationships between the organisations that lead them. To be blunt, even where these relationships are more developed, they can hardly be described as high maturity, and where they are bad, they are basically dysfunctional.

This should not be a surprise. Anyone who has attempted to work across multiple organisations knows that just calling something a ‘system’ does not axiomatically lead to seamless integration.

The relationships that underpin ICBs are complex and, at times, ambiguous. These relationships also exist within and are subject to the effects of a volatile and ever-more challenging operational environment.

The inadvertent creation of a SINO (system in name only) is a very real danger for community leaders and policymakers alike, a structure that may meet the basic expectation of joint working but sadly misses the point of creating lasting impact.

Further structural fiddling is not the answer. The basic principle of integrated responsibility and accountability is the right one for better outcomes. Achieving the level of relationship maturity needed to make a system effective is a considerable challenge and one that will require resources, commitment and political patience to fully realise.