Integrated care systems must not be smothered by too many objectives

With every area of the country set to be covered by an Integrated Care System by April 2021, the planning guidance due later this week is another key milestone as we move to a “systems by default” approach to planning and delivery in the NHS.

The direction of travel is well supported and the expectation is that local services will provide better and more joined-up care for the public when different organisations work together more effectively.

ICSs vary significantly in the needs their local populations face and are well placed to work through what is likely to be the best approach for their local context. They will be central to the delivery of the ambitions set out in the NHS long-term plan, notably around better integration of services for the public and easing pressure on acute and emergency services.

Yet there remains considerable uncertainty about the accountability arrangements of ICSs which are essential to underpin successful delivery.

That’s why the NHS Confederation brought together a group of senior leaders from across the NHS, local government and the voluntary sector to explore ICS accountability.

Three areas for greater clarity

There are three areas where it was agreed greater clarity should be provided: the mutual accountability of partners within each system, nationally to arms-length bodies and locally to their communities.

On the first point, greater clarity about the function of ICSs and developing a clear set of outcomes to deliver collectively were viewed as critical tasks for achieving more robust internal accountability. Through giving a sense of shared purpose around the needs of local communities it is possible to build a sense of mutual accountability.

More integrated national policy making is also needed that reflects the broader based approach to improving the health and well-being of the local population being taken by systems

ICSs should also reach a clear understanding locally about how their role and function fits with the existing roles performed by the constituent organisations and stakeholders. Local relationships and ways of working should be given time to develop and work these issues through before consideration of future statutory change. That said, there may need to be some adjustment to legislation to reconcile organisational objectives with system working.

On the second point, there needs to be a shift to a more mature oversight and regulatory relationship with systems driven by local needs and aspirations. The regulatory relationship needs to be re-framed so that local system plans set the agenda for conversations with arms-length bodies and regulators about how and where systems will make a difference. More integrated national policy making is also needed that reflects the broader based approach to improving the health and well-being of the local population being taken by systems. In particular, the lack of a clear national policy framework for adult social care is a concern.

On the final point, local accountability should be driven “from the ground up” within an ICS area. Primary care networks and integrated care partnerships should be used to drive forward an agenda of improving the lives of local people. However, they should not be “smothered” by attaching too many objectives to them at an early stage.

The long-term plan’s emphasis on using local systems to improve population health and wellbeing is a welcome approach, which we feel provides genuine opportunities to create more effective health and care systems.

In order to allow these systems to operate to their full potential, we need to reimagine how accountabilities will work, maximising the benefit of existing structures where appropriate, but also redrawing other relationships to enable a more decisive move away from the “top down” approaches of the past.

Much more thinking is needed locally and nationally on this subject but we hope our report will support the local development of ICS accountabilities alongside further national thinking about the future direction of travel needed to allow ICSs to operate to their full potential.