eNHS 3.0 Can a local, integrated care system deliver better outcomes for patients?

Integrated care systems were relatively new ideas that emerged from the NHS Long Term Plan. In the last few months, however, and particularly since the release of NHS England’s paper in November 2020, the direction of travel for ICSs has fundamentally changed.

The paper proposes two new options that will decide the direction and the statutory composition of each integrated care system across the country. It emphasises the creation of provider collaboratives and primary care networks with a distinct role at place, and states the intention to enable more resources to support integrated provision.

Additionally, one of the aims of the new legislation is to deliver improved population health, improve quality and outcomes and achieve financial sustainability. This is about more than just reconfiguring the health sector and integrating social care.

The new legislation reinforces the objective for the NHS to move away from a competitive market to one much more focused on collaboration, with the citizen at the heart of everything and a stronger focus on improving population health. Existing NHS governance arrangements will require significant changes if ICSs, supported by ICPs and PCNs as the delivery vehicles, are to move healthcare towards this new model.

GGI’s response to NHS E/I’s paper

Given GGI’s wide-ranging contact with the nation’s ICSs we felt in a strong position to respond to the consultation and have outlined our main views following conversations with clients and various events held.

1. There was variation in response to the paper. Individuals and organisations have reacted in a variety of ways to the paper. We have already seen some ICSs in the initial phases of developing governance frameworks and terms of reference for system boards, with sound and competent decision-making abilities.

2. Systems feel more power should be devolved. We would encourage the centre to be locally permissive, because we have detected a degree of cynicism around an over-centralisation of power. While systems provide a balance across wider populations, place will provide a better centre for engaging with citizens and delivering care as close as possible to the patient.

3. ICS working cannot just be seen as driven by the NHS. We have repeatedly heard that the proposed ICSs are simply a power-grab and an NHS construct, with other partners as secondary. During one of our National Commission events, one local council leader said councils are willing to give up the power for the greater good but other system players were not. For ICSs to achieve their goals it must feel like a collaborative effort.

4. Lack of understanding for care homes and domiciliary services. Care homes and domiciliary services have not been taken sufficiently into account. Our research shows a significant gap in understanding about this critical sector and the precarious financial balancing act for keeping it viable. Their greater involvement in planning could support goals and objectives set out by the system.

5. Increased importance should be given to ICPs and place. The greatest opportunity to make ICSs effective will be to support place and ICPs to plan and deliver care close to the patient. While ICSs will have a general oversight of the system, each place is unique. Allowing greater freedom at place will support the delivery of care most needed by local populations.

6. Composition of place. There are many different definitions of place. There is an argument that place should be moulded around each local authority rather than an acute trust’s footprint. This composition could alleviate any tensions of this being an ICS construct and rather that is it about cross-sectoral collaboration.

7. The development of provider collaboratives are also strongly supported. Provider collaboratives are an important form of horizontal alignment and integration. Done correctly, they will be better at standardised care. This may take some time to get right but a well-run provider collaborative will bring with it a wide range of benefits without impacting place independence.

8. Partnership working necessitates a mindset shift. Adopting and instilling the correct mindset for shifting towards a more collaborative system-focused model is essential. With the possible development of partnership boards, delegates will need to ensure their decisions are made with the best interests of the population at heart, not just a single organisation.

9. Systems and place will benefit from independent chairs and non-executive oversight. Chairs and non-executive directors hold important roles on boards – NHS and beyond. The inclusion of system NEDs (SNEDs) will benefit ICS and ICP boards, not least so that proper audit committee functions and conflicts of interest can be managed.

What does this mean for the healthcare sector?

The move to collaborative system working is the right way forward and something that has progressed throughout the pandemic. However, it is important to ensure that any future legislation is not just seen as an NHS construct but one of co-production between all members working within a system.

Improving population health outcomes should not be about one sector taking charge but a cross-sectoral harmonious gathering of organisations with a clear focus on peoples’ wellbeing and addressing the determinants of ill-health.

We are currently working with a number of ICSs across the country and interact with many more through events such as our webinars and National Commission work. If you would like to know more about our offering or would like some advice, please call us on 07732 681120 or email advice@good-governance.org.uk.

Illuminations

• Cultural change in and between organisations will be one of the biggest challenges to achieving the positive and successful outcomes systems can create.
• Different sector partners will complement each other, add value to the systems in different ways and should be consulted in all major system conversations.
• ICSs across the country are at different levels of development and should share best practice between each other to improve system development

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk