The Integrator: Five questions about ICS development

With the bold target in the NHS long-term plan for all of England to be part of an integrated care system by 2021, it is clear that the days of Lansley’s focus on competition are behind us, with integration the desired nirvana.

What’s still far from clear, however, is how this transition can happen within a tight timeframe, and a few points in particular raised an eyebrow or two:

Where do councils fit in?

There seems to be a significant downgrade on integrating health and social care. At best the plan talks about integrating health and social care at place level – that means care that is commissioned for populations of 150,000 to 500,000. While this might make more sense given the ongoing difficulties sustainability and transformation partnerships and ICS have had working with councils, it seems an admission that the initial ambition to integrate across a larger region might not be viable.

The plan said new ICS boards must have representatives from NHS commissioners, trusts and primary care networks but – in one of its most telling sentences – said there was a “clear expectation that [local authorities] will wish to participate”. In reality this means there will be regional variation in how well people who need both social care and health care are supported, as NHS England does not have the mechanisms to demand local authorities get involved.

Of course none of this is helped by the continual delay of the social care green paper – which even when it finally emerges I’ve heard could be so “green” it will fail to answer the prime issues about funding.

What about the patients?

There was a lot of talk about structural reorganisation in the plan but little about how this will directly benefit patients. The Nuffield Trust’s paper on integration, released earlier this month, couldn’t have been more timely, as it raised concerns that to date patients have seen little benefit from current integration work, with patients and carers overall feeling less supported. It also found that there are no patient surveys that ask people about the coordination of care between services.

There’s a new proposal in the plan to create an integration index which will ask “patients, carers and the public’s point of view” as to how well local services are providing joined up care. Although the system has battled to implement similar ideas before, some measurement will be vital to ensure that the NHS isn’t just shuffling the deckchairs with no results.

How to enforce collaboration

I’ve written before about legislation and although there were clear asks in the paper about changes that would make system working much easier, with ongoing Brexit chaos worsening by the day, legal changes remain very unlikely in the medium term. Without it, some of the asks in the plan seem impossible.

For example, NHS England said it may introduce new licence conditions for trusts to ensure they take on system responsibilities too. However, if the statutory duties of trusts do not change, it will be very challenging to put them under two conflicting legal obligations.

Similarly, it said trusts and clinical commissioning groups would be under a “duty to collaborate” and “neither trusts nor CCGs will pursue actions which, whilst potentially improving their institutional financial position, would result in a worse position for the system overall”. But is it viable to demand CCGs collaborate when this may result in them breaking their statutory duties to break even?

How to avoid a two-tier NHS

These questions also make spreading ICS across the worst performing areas even harder. The plan said most “challenged systems” will be subject to an intensive support programme from NHS England and NHS Improvement which will include peer support from more developed ICS. But if the relationships are poor and collaboration cannot be enforced, there’s a real risk that by 2021 some areas will be an ICS in name only.

Similarly the idea of peer support may sound great on paper but I’ve heard from a few of the leading ICS areas that they are already struggling to manage the workload in their only localities and uncomfortable with branding themselves experts on integration transformation.

What about the money?

Shared or system control totals is not going brilliantly among the current 14 ICS. In quarter two data released by NHS Improvement only eight had accepted a system control total and of these three were significantly overspending against plan, with Nottinghamshire the worst with an overspend of £24m. One of the original eight ICS, Buckinghamshire, had not been able to accept a control total at all due to an unexpected overspend by its CCG.

These current issues put into stark relief how hard it will be to introduce contract reforms from 2019-20 onwards to support the creation of ICS. The idea of introducing “earned financial autonomy” for local health systems may sound a good one but without a solution to the conflict of interests between organisational and system duties, many will struggle to get off the starting blocks. How relationships in the existing ICS survive their widening financial gaps at the end of this year will be telling.

New contracts, such as through provider alliances, may help solve some of the concerns but it must be a blow to NHS England that the first integrated care partnership contract has been delayed by a year as the commissioner, Dudley, is struggling with the how complex the task is.