Written evidence submitted by NHS Confederation
The NHS Confederation is the membership organisation that brings together, supports, and speaks for the whole healthcare system in England, Wales, and Northern Ireland. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care, and reducing health inequalities.
Our Integrated Care Systems (ICS) Network is the only independent national network which supports ICS leaders to exchange ideas, share experiences and challenges, and influence the national agenda. We are delighted to have all 42 ICSs in membership.
The health and care system faces long-term challenges: demand for care is rising, largely driven by an aging population and rising multi-morbidities, which is driving increasing waiting times for care, pressure on NHS staff and additional financial pressures on the public purse.
Against this pressure, and to improve health outcomes and patient experience, we need to make smarter use of our resources: preventing ill-health in the first place on the demand side and improving the efficiency of services on the supply side by delivering the right care in the optimal setting through a more integrated approach to planning and delivery.
This is the role of ICSs. While ICSs will not be a panacea, they are well-placed to drive a shift in focus within our health and social care system as they bring all the relevant partners together to make decisions collectively. In the longer term, their advent will make our health and social care services more sustainable both locally and nationally.
Our response to this Public Accounts Committee inquiry focuses on the role of ICSs including the work they do, highlights how they are already making a difference through local case studies, and sets out the key challenges they face and how these risks can be mitigated.
What is an Integrated Care System?
1. ICSs were put on a statutory footing on 1 July 2022 with the purposes of:
2. ICSs are now responsible for planning and funding health and care services in the area they cover. They were set out as part of the NHS Long Term Plan from 2019 and build on how services have been working together already at local levels to orientate health and care much more around the people they serve rather than their organisational boundaries. Their establishment represents the first large-scale structural change to the NHS since 2012.
3. ICSs are partnerships that bring together the health and care organisations including local government in a particular area, serving anywhere between 542,000 to 3.51 million people, to work together more closely and provide joined-up care.
4. The 42 ICSs replaced the now dissolved 106 NHS Clinical Commissioning Groups (CCGs) that came before them on 1 July 2022.
5. Each ICS is made up of an integrated care board (ICB) and an integrated care partnership (ICP). The ICB is an NHS body, with members nominated by NHS trusts, providers of primary medical services, and local authorities. The ICB receives funding from NHS England for commissioning NHS services across the ICS area.
6. The ICP is a committee jointly formed by the ICB and local authorities in the ICS area, with other invited bodies, for example third sector organisations. It creates an Integrated Care Strategy that sets out how the health and care needs of the local population will be met by the ICB, local authorities and NHS England. These bodies must then have regard to the strategy when planning and delivering services.
7. The new governance arrangements are designed to facilitate a more collaborative approach within and across health and care to the planning of services. This will require culture change over the coming years, with individuals in different health and care organisations working more closely together – the new structures will not deliver culture change overnight but provide the foundation to support this.
What will ICS do in the medium to long term?
8. Firstly, ICSs will help keep people well by facilitating population health and preventative models of care, which will help manage increasing demand for care, ease acute pressures in urgent and emergency care and reduce health inequalities, both in the medium and longer-term. ICSs are well-suited to work in place-based partnerships and identify those most at risk of poor health outcomes, enabling the targeting of greater investment into the social determinants of health and empowering other parts of the system such as primary and community care.
9. As only 10-20 per cent of health outcomes are determined by NHS care, greater collaboration between the NHS, local authorities and VCSE organisations to improve people’s health and wellbeing will be essential. ICSs bring all these organisations into their one forum in Integrated Care Partnerships (ICP). Collaboration should also make the delivery of care more seamless, improving patients’ experiences and outcomes.
10. Secondly, ICSs will also help to improve services (the supply of care) by redesigning care pathways, so patients receive the right care, from the right people, in the best setting.
11. This requires the deployment of multidisciplinary teams from different organisations to review and revise whole patient pathways together, determining what care and treatments they get from different care providers at difference stages.
12. In practice, this will see organisational and professional siloes being broken down, more streamlined delivery of care by sharing resources and risk across the system – notable through shared workforce planning. This will feel very different for patients, especially those with long-term conditions and multi-morbidities, whose care should be delivered more seamlessly and without the need to repeat their story to each professional as they interact with different parts of the system.
How are Integrated Care Systems already making a difference?
13. There are already examples of the impact of partnership working through ICSs, in both improving patients’ experiences and making the NHS more sustainable, with many systems forming partnerships and working together informally years before they were put on a statutory footing in July:
14. Leicester, Leicestershire and Rutland ICS piloted a scheme during the pandemic to provide people with significant frailty/complex comorbidity with the choice to receive care in the community as an alternative to hospital admission where this could improve their safety, experience and outcomes. The initial pilot led to the appropriate avoidance of 577 hospital admissions and 2,885 bed days, the saving of 730 ambulance journeys, and financial savings of at least £395,245.
15. In Lincolnshire ICS, senior clinical leaders are piloting an entirely different model of care for patients, a model without external referrals, hand offs, waiting lists, discharges and referrals. A model in which primary and secondary care were not operating in separate domains, but as one clinical network, working together to provide patients with seamless care – primary care led integration into secondary care. In July 2020, they formed the Connected Health Network (CHN), which worked with a local Primary Care Network, the Meridian Health Group, to pilot this new model in cardiology. Within the CHN model follow-up appointments are vastly reduced and the average waiting time for new patients to be reviewed by a specialist is under 2 weeks, compared with a 16-week wait for routine cardiology referrals into the Trust previously. They plan to expand this model to other specialties in medicine, surgery and women and children’s services.
16. Four acute trusts in the Black Country Provider Collaborative have brought together orthopaedic teams from each provider to improve service provision and make better use of existing capacity. Clinicians from each provider created two elective hubs which will deliver almost all the elective orthopaedic activity across the Black Country ICS and help tackle their elective backlog more quickly.
17. In South Yorkshire ICS, nearly 200,000 people in the population smoke, with more than half of this cohort dying prematurely from smoking-related illnesses. In partnership with the Yorkshire Cancer Alliance, five local authorities, the acute trusts in their area and local stop smoking services launched the QUIT programme to address this challenge. The programme aims to lower mortality rates, decrease hospital readmissions and reduce health inequalities by making effective treatment for tobacco addiction part of the routine care offered in hospitals.
18. West Yorkshire ICS is supporting its learning disability population and families by harnessing the scope of the NHS’s Transforming Care Programme to ensure early intervention support is readily available to these individuals and their families. Partnership working with the VCSE sector through the care (education) and treatment reviews means that fewer young people with learning disabilities are being admitted into assessment and treatment hospitals.
19. Police, social care, the NHS and other partners within Devon ICS worked together to form One Northern Devon, which developed a programme to help regular users of accident and emergency (A&E) and other emergency services. Caseworkers worked with individuals with complex needs to develop plans to co-ordinate support from various services to tackle issues such as housing and finance, preventing them from reaching crisis point. The scheme simultaneously improved the lives of their service users and helped to reduce A&E visits by 60 per cent, saving the taxpayer £200,000.
20. ICSs will be developing strategies and delivery plans through 2022/23 which should provide milestones for the process of integrating care going forward. We are supporting ICS leaders in the development of their long-term strategies.
What are the key challenges facing Integrated Care Systems?
21. There are major challenges that may undermine the ability of ICSs to drive the changes they want and were set up to make, but these risks can be mitigated if ICS leaders are given the agency, autonomy and resources they need to fulfil their four key purposes which are outlined in the first paragraph.
22. There is huge variation between ICSs in their size, the demography of their local populations and maturity of integrated working – in addition to the local organisations and their arrangements for joint working. ICB budgets range from £0.9 to £6.9bn reflecting the different populations they serve. Formal commencement of statutory ICSs began on 1 July, but systems have been forming relationships and partnerships for years. They are all at different stages of development. A permissive framework which allows local flexibility to make decisions and measure progress against fewer targets that are more focussed is needed for ICSs to deliver against their statutory responsibilities and continue to make a difference to communities.
23. NHS England’s new operating framework is a key development for clarifying the relationship between system leaders and NHS England’s national and regional teams and where functions will be delivered. It sets out the ways of working that will enable NHS England to deliver its purpose as a new organisation when it formally merges with Health Education England and NHS Digital in April 2023. We welcome the commitment to iterating the model in collaboration with ICBs and providers and to developing a longer-term organisational development programme to enable the cultural and behavioural changes needed to support system working and give ICSs space to lead.
24. However, the framework is not evidence of a substantial shift away from a top-down regulatory intervention model towards one of enabling and supporting improvement, involving peer-to-peer support and sharing. There is a risk that the way ICBs and their functions have been presented implies that they act as an additional layer of bureaucracy or management which could inhibit their role in longer-term supporting transformation and improving population health. We hope these things will be addressed in future iterations of the model and in the upcoming new oversight framework.
25. The regulatory landscape is complex and needs to be joined-up. Regulators need to operate in a way that reflects both the ICB’s role as an accountable NHS body and the role of the ICP as a partnership of equals between the NHS, local government and other partners who all shape health outcomes, while at the same time respecting local governments’ independent mandate to their electorates. Locally determined measures will help to achieve this; primarily nationally driven performance targets risk crowding out local priorities and inhibiting ICSs’ ability to improve care and services for their local populations. Indeed, NHS England’s most recent Planning Guidance included over national 100 priorities for systems to deliver. It was disappointing not to see the importance of the role played by the ICP reflected in NHS England’s new operating framework. This should be given more thought as the framework is evolved.
26. The need to meet performance targets (particularly reducing waiting times and the elective care backlog) and balance budgets in the short-term risks undermining investment of time and effort in the transformation ICSs need to deliver to improve patient care and make the health and care system sustainable in the long-term. Accountability should consider both and system leaders should be empowered with autonomy to deliver longer-term change. More time is needed to develop appropriate metrics for integration and outcomes which are supported by ICS and national leaders, while allowing flexibility to include local priorities.
27. Given constraints on NHS and social care funding, difficult choices need to be made about where to prioritise investment. These choices are best made as close to local populations as possible – by local leaders – and they need greater flexibility to decide how to use their resources and measure success against local priorities. ICSs tell us that repeated invitations to bid for short-term funding pots for nationally ring-fenced projects, rather than having resources available up front to spend on local priorities, undermines local autonomy and efficient use of public resources.
28. Key factors which will determine the success of ICSs are outside of their control. Workforce supply, capital investment and flexibility, social care capacity and their level of autonomy are factors largely outside of ICS leaders’ control, but can be affected by central government, which will determine whether ICSs succeed or fail and shape patients’ care and experience. A failure by government to act on these national issues will act as a fundamental barrier to the success of ICSs and in turn, the health and wealth of local communities.
29. The introduction of integrated care systems presents a unique opportunity to plan and deliver patient care differently across the NHS and social care. But as National Audit Office review into ICSs rightly recognises, change will not happen overnight and local systems need the time, space and support to deliver on their ambitions.
30. That means government action to address the fundamental challenges of constrained funding, huge staff shortages, lack of capital investment and commitment to tackle health inequalities. It also means committing to no further structural reorganisation for the next decade so that the current reforms can be embedded.
 Hood, C. M., Gennuso, K. P., Swain, G. R., Catlin, B. B., 2015. ‘County Health Rankings: Relationships Between Determinant Factors and Health’ Outcomes. American Journal of Preventive Medicine: https://www.ajpmonline.org/article/S0749-3797(15)00514-0/fulltext
 Based on 2021/22 funding allocations.
 NHS England, ‘2022/23 priorities and operational planning guidance’, 24 December 2021.