Should integrated care systems be performance managers?

“If you think competition is hard, you should try collaboration.” That quip from Rob Webster, the lead for the West Yorkshire and Harrogate Integrated Care System, broadly says it all. Leading an ICS, or one of their progenitors, a Sustainability and Transformation Partnership, has to be one of the tougher jobs around.

After all, these things have no statutory basis. Their chairs and leads have no formal authority. They are coalitions of the willing – both the more willing and the less so. The aim, working in conjunction with local authorities and the various incarnations of the independent and voluntary sectors, is to produce better integrated care and a more population-based approach to health than the “choice and competition” model of the purchaser/provider split either encouraged or produced.

In the absence, when they were first proposed, of any prospect of legislation following the car crash of the Health and Social Care Act 2012, they are also a large-scale test of whether people, working together in their own localities, can produce more lasting and effective change than yet another formal, statutory, re-organisation of the NHS. [Not that there is not rather a lot of re-organisation going on under the hood as ICSs are created, CCGs are merged, and NHS England and Improvement move closer together through the recently created regions.]

System leadership

So over the summer, The King’s Fund interviewed a dozen-plus leaders of these beasts – both chairs and the more executive leads – about the skills needed and the challenges faced. The skills needed for system leadership (for that is what this is) are pretty well known now and were indeed played back by the interviewees. Endless meetings.

Large amounts of shoe leather are consumed, along with keyboard time, telephony and tea, as visions are painted, connections made, ruffled feathers soothed, and clogged wheels oiled. Much work goes into assembling the evidence base for change, because evidence both persuades and creates the peer pressure to achieve it.

Along with that goes an ability to remain permanently optimistic in the face of setbacks. “An unwavering ability to keep cheerful” as one lead put it, while from the chairs and others came the recognition that part of their role is to provide “air cover” from the less reasonable whims of the centre.

These interviewees were pretty united about the sorts of “soft power” and authority that they do in fact have. But, perhaps unsurprisingly given that these remain “make it up as you go along” creations, they were much less united in their views about to whom they felt accountable: whether to “the centre” in its various incarnations, or their members, or indeed the public and patients to whom they all ultimately felt accountable without the mechanisms obviously being there.

Many agreed that in time these organisations will need to meet in public (the odd one or two already do). And quite a few that it is more than likely that ICSs will eventually have to become statutory organisations.

They held that view, however, in a very St Augustine way. “Lord make me pure, but not yet” – given that the governance of these systems remains in a semi-permanent state of flux, and very varied, as people continue to work out quite what an ICS is and thus how it should be governed.

As a broad generalisation and with notable exceptions, relations with local government seem to be improving. Many of the STPs have dropped that title, perceiving it to be a “toxic brand” given the accusations, not least from local government, over a lack of transparency in the original plans and a distinct absence of the “partnership” that was in the title.

What also emerged were clear worries about the pipeline of future leaders of ICSs – for a whole bunch of reasons, including a shortage of people with experience of working across systems.

But the knottiest issue that emerged was the question of quite how “load bearing” STPs and ICSs should be. They are clearly planning and implementation bodies. But how far should they – how far can they – become performance managers: responsible for both quality and financial performance?

There were divided views on that. Some keen to take it on. Others much more cautious. Not least because, as one put it, if a big unexpected financial black hole opens up, or there is a major clinical scandal, would an ICS be left to sort that out themselves?

Intimately tied to that are two other issues. Whether ICSs will be relatively thin organisations, doing only what needs to be done at a system level as most of what is involved in integrated care happens much more locally.

Or whether they will become rather more health authority-like structures, and themselves more directly answerable to the regions and the centre. The general election, depending on its outcome, may make such questions redundant. But they are key among the current concerns.

’Leading for Integrated Care’ by Nicholas Timmins, is published by The King’s Fund on Wednesday 27 November 2019 and is available to read and download at: https://www.kingsfund.org.uk/publications/leading-integrated-care