Delivering Patricia Hewitt’s ICS vision on a shrinking budget

Patricia Hewitt, recently, published her review of integrated care systems. ICS leaders and stakeholders will be looking at how to deliver her vision for the future in the context of 30 per cent budget reductions by 2025-26.

One of the approaches recommended by Ms Hewitt (and Amanda Pritchard) is to use integration to deliver “economies of scale”: “Local government and NHS partners, including the integrated care board, need to work together within individual ICSs to share corporate services and other functions, create single teams and make better use of digital tools to improve productivity. Neighbouring ICSs need to consider similar arrangements, such collaboration helps to strengthen ICSs while achieving better value for public funds.”

When looking at collaborative solutions there are some established models worth considering:

Subcontracting

The parties may identify that one member can provide specific services better than others. This service could be offered with the ICS being a client of the member. The contract needs to include appropriate terms, a well-defined specification and key performance indicators to ensure the required outcomes are delivered.

There will always be a slight power dynamic in contractual relationships due to the nature of the head provider and the subcontractor’s roles. This can be offset by the parties agreeing to shared oversight, integrated governance systems and by underpinning the formalities with strong relationships. Using subcontracts provides a legally sound structure to underpin the collaborative working requirements.

Be aware that this approach may result in some people transferring from one provider to another to form the new team.

Specialist joint ventures

Forming a dedicated service provider by creating a single integrated entity, allows resources to be pooled in a new legal vehicle, hosting specialist teams supporting multiple ICSs and their members. They may be able to utilise section 75 of NHS Act 2006 to formalise the relationships with the secretary of state’s consent.

Many NHS trusts and local authorities have experience of forming such entities for property and administrative functions. They may be complicated but can offer a long-term solution for delivering high-quality services at scale, and could service multiple ICSs.

To ensure the delivery of integrated services it is important to maintain shared ownership and direct relationships with these entities and each other.

Outsourcing

Where there are existing service providers available from both the public and private sector, ICSs may wish to procure the services from them. This approach works where there are known levels of expertise within the sector and especially when the support is likely to be on an ad hoc or project basis. Fees may be higher but the cost may be offset by the speed of work, a reduced management burden and the ability to rely on third party indemnities.

Insourcing

Insourcing has similar benefits to outsourcing but with the additional benefit of bringing in dedicated teams to advise and work on specific projects. This may include secondments of teams or individuals between different providers, or it could be in the form of specialist third-party providers. The benefits of this model have been successfully shown in waiting list management.

Summary

In all scenarios, ICSs must ensure they access appropriate support and advice in structuring their contracts. These decisions and models are complex, with potentially significant impacts on staff. Employment advice is particularly essential: engagement will be required with staff and unions, Transfer of Undertakings (Protection of Employment) regulations complied with where relevant, and pension entitlements managed appropriately.

This period in ICS development may be challenging but there are existing models and examples to draw from, and the expertise to define the roles is available.