Written evidence submitted by The Health Foundation (ICS0063)

About the Health Foundation

The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Our aim is a healthier population, supported by high quality health care that can be equitably accessed. We learn what works to make people’s lives healthier and improve the health care system. From giving grants to carrying out research and policy analysis, we shine a light on how to make successful change happen.

Background and introduction

Integrated care systems (ICSs) were the centrepiece of the Health and Care Act 2022 – the biggest legislative overhaul of the NHS in a decade.[1] On 1 July 2022, England was formally divided into 42 ICSs, covering populations of around 500,000 to 3 million people.

ICSs are based on the idea that collaboration between local health and care agencies – such as NHS trusts, local authorities, general practices, social care providers, and others – is needed to improve services and make the best use of public money.[2]

ICSs have inherited responsibility for managing NHS services at a time of intense and growing pressure on the system: staffing shortages in health and social care are chronic,[3],[4] record numbers of people are waiting for routine hospital treatment,[5] and health inequalities in England are wide and growing.[6] ICS leaders face a daunting task.

In response to the Committee’s call for evidence, we summarise relevant work on ICSs in a small number of areas linked to their accountability. We structure our response under four broad headings to cover: what ICSs look like and how they differ, implications for measuring and assessing the performance of ICSs, how local agencies work together to improve health and reduce health inequalities, and the broader policy context for ICSs. We end with a short conclusion identifying some outstanding questions for national policy on ICSs.

Section 1: how do ICSs differ?

ICSs vary widely in structure and complexity.[7] The average population covered by an ICS is around 1.5 million people. But the range is large (just over 500,000 in the smallest ICS to more than 3 million people in the largest). Bigger ICSs tend to involve more health and care organisations. For example, some systems cover more than 10 upper-tier local authorities, while others cover just one. Bigger ICSs are also likely to involve more ‘places’, which will involve additional governance and infrastructure (such as more local committees).

The complexity of the organisational landscape within each ICS is likely to affect how the system functions – for example, by making it easier or harder to make decisions and implement service changes. Differences in governance and decision making between organisations – for instance, between the NHS and local government – can hold back partnership working.[8] And evidence from past integrated care initiatives in England suggests that having fewer participating organisations – ideally with similar geographical boundaries – can help facilitate faster progress.[9]

The historical context in each ICS will also have a strong influence on how local agencies work together and redesign services.8 For example, the existing relationships between hospitals, GPs, and other agencies will shape how ICSs develop. Some parts of the country may have a head start through their involvement in previous policy initiatives on integrated care – including new care model ‘vanguards’ and integrated care ‘pioneers’. The experience of working together in previous versions of ICSs will also make a difference.

ICSs have been given broad aims by national policymakers, including to: improve outcomes in population health and health care; tackle inequalities in outcomes, experience and access to services; enhance productivity and value for money; and help the NHS support broader social and economic development.[10] But the task facing ICSs is not equal. Pressures on services, health inequalities and the health of the population vary widely, as do the resources to address these challenges.7 For example, mapping how deprivation is distributed between ICSs paints a stark picture: nearly half of neighbourhoods in some ICSs are in the most deprived fifth of neighbourhoods nationally, compared with less than 1 per cent in others (see figure).7

Variations within the NHS are nothing new. But these differences will shape how ICSs function. And they mean progress will differ between systems, given their varied contexts and starting points. National policy on ICSs must acknowledge and reflect this variation.

Section 2: what are the implications for system-wide measurement?

The shift to ICSs will mean some changes in how local leaders are held to account for performance. Overall, the aim of measuring performance across local health systems is a good one. But the approach to measurement and assessment of ICSs is currently unclear. A mix of policies are under development: the Care Quality Commission (CQC) is developing a new approach to assuring local systems,[11] NHS England is due to consult on a ‘long-term model of proportionate and effective oversight of system-led care’,[12] and an outcomes framework for the ‘place’ level of the system was proposed in the integration white paper earlier this year.[13]

The right approach to measuring local health system performance depends on policy objectives – for example, whether policymakers want to judge ICS performance, support local systems to improve services, provide information for the public to understand the quality of services, or some other objective.[14] Holding local leaders to account for the performance in their ICS is clearly essential. But national NHS bodies should also consider how they can use ICS measurement to support local learning and improvement. This means providing data that are meaningful to ICSs and helping them use the data to inform action.

Any future approach to measuring and assessing ICS performance should learn lessons from other countries and draw on the work of previous reviews.[15] These point to the need for simplification and alignment of existing measurement frameworks, which risk unnecessary complexity and duplication. They also emphasise the need for wider engagement to ensure any assessment framework reflects what really matters to patients and the public.

In selecting indicators, policymakers should also learn from past attempts to assess STPs – ICSs immediate predecessors. These measures were imbalanced towards hospitals, too narrow in scope to fairly reflect system-wide performance, and too simplistic to be meaningful.[16] Measures to track ICS performance should therefore reflect the broad range of objectives for local systems and avoid overly simplistic comparisons between areas.

In setting out expectations for the performance of ICSs, national policymakers must acknowledge the wide variation between local systems and implications for their progress.7 The differences between systems should be reflected in how ICS performance is assessed and reported. For example, publicly reported data should link ICS performance to the underlying resources and context in each area to allow comparisons on relevant indicators between ICSs with similar levels of deprivation. More broadly, policymakers should be realistic about what ICSs can achieve and how long it can take to implement changes in care. For example, developing new models of community-based care can take several years to develop and deliver results[17],[18] – even with significant investment and local engagement.[19]

Section 3: what factors shape partnership working?

New NHS integrated care boards (ICBs) are being established to manage most health care resources in each ICS area. But many other statutory organisations – local authorities, NHS trusts, general practices, and others – will be involved in local planning and decision-making. This means that accountability for improving local services is spread between multiple agencies, who will need to work together effectively to deliver ICS’s objectives.

Partnerships between local agencies to improve health are nothing new. But despite this long history, evidence that local health partnerships deliver the kind of benefits that policymakers typically expect is lacking.[20] Making collaboration work in practice is challenging, and the role of national policy and political choices is often underplayed.[21]

ICSs can learn lessons from the earlier versions of integrated care systems in England. These were criticised for having limited involvement of local government and other community partners, and ‘lifestyle drift’ in strategies for improving population health.[22],[23]

Local agencies can also learn from the various factors that have helped or hindered past collaboration efforts. A recent review of the evidence on local health partnerships grouped the factors influencing how partnerships function into five overlapping domains:

-                                                                                                                                                                                                                 motivation and purpose – eg vision, aims, perceived benefits, and commitment to collaboration. For example, unclear or unrealistic aims may hold back collaboration

-                                                                                                                                                                                                                 relationships and cultures – eg trust, values, and communication. For example, historical relationships between agencies can shape collaboration efforts

-                                                                                                                                                                                                                 resources and capabilities – eg access to funding, staff, and skills. For example, lack of resources for joint working is commonly identified as a barrier to collaboration

-                                                                                                                                                                                                                 governance and leadership – eg decision making, engagement, and involvement. For example, community involvement may help collaborations be more effective

-                                                                                                                                                                                                                 external factors – eg national policy, institutional contexts, and geography. For example, national policy changes may confuse or conflict with local priorities.8

Data linking these factors to collaboration outcomes are limited, but some factors are likely to have a more powerful influence than others. For example, good communication between local agencies may help coordinate complex interventions. But broader political decisions about the level and distribution of funding for the NHS, local government, and other services will fundamentally shape local resources for improving health and reducing inequalities. The Health and Care Act 2022 introduced changes to NHS structures and rules to encourage partnership working at a local level. But national policymakers must now focus on the broader policy changes and support needed to enable partnerships to work in practice.

Section 4: what does the broader context mean for ICSs?

Looking ahead, the extreme pressures facing NHS and social care services in England will be compounded by a gloomy economic outlook and rising inflation that will eat up a share of planned health and care budgets.[24] Government’s failure to provide additional funding to cover recent increases in NHS staff pay will put even more pressure on already over-stretched budgets.[25]

More broadly, spending on social care is barely enough to keep up with demand, public health funding is flat, and local government spending is on track to be smaller in 2024-25 than in 2010.[26],[27] Government has set ambitious targets for reducing health inequalities in England, but has so far failed to deliver the policy changes or investment needed to achieve them.[28],[29],[30] Without sufficient funding or a clear national strategy for reducing health inequalities, integrated care systems risk being set up to fail by national policymakers. 

Outstanding questions

Establishing ICSs as the new regional tier of the NHS in England was intended to improve the previously murky accountabilities in the health system.2 But several questions remain about how the constituent parts of ICSs will work in practice and how they will interact with other parts of the health system. The relationship between emerging NHS provider collaboratives and the new integrated care boards (ICBs), for example, is currently unclear. And questions remain about how NHS providers will balance their duty to collaborate with existing responsibilities as individual organisations. There is still limited detail on how the new ‘place’ level of the NHS will be organised. And there is a risk that integrated care partnerships (ICPs) end up playing a bit-part role in the new arrangements, side-lined by more powerful NHS agencies. This would undermine government’s aims for better integration of services beyond the NHS and limit the ability of local systems to tackle the social and economic factors that shape health and health inequalities.

Links to relevant Health Foundation work:

• Integrated care systems: what do they look like? (June 2022)
• A cure for everything and nothing? Local partnerships for improving health in England (BMJ, July 2022)
• Will a new NHS structure in England help recovery from the pandemic? (BMJ, February 2021)

References