ICS0012

Written evidence submitted by NHS Providers

About NHS Providers

NHS Providers it the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those foundation trusts and trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping them to shape the system in which they operate.

NHS Providers has all trusts in England in voluntary membership, collectively accounting for £104bn of annual expenditure and employing 1.4 million staff.

Key points

Trusts support the development of integrated care systems (ICSs). They recognise that changing health and care needs mean that services and organisations need to work together in different ways, including across systems, through place-based partnerships, provider collaboratives and joint work at neighbourhood level.

Trusts recognise that ICSs have a complex set of objectives support the four core purposes set out by NHS England (NHSE). Many trust leaders are particularly enthusiastic to harness the opportunities of partnership working and of provider collaborations within systems, and to develop ways of working which better meet the needs of people experiencing deprivation and health inequalities.

The new statutory framework is an important point in the journey to embedding partnership working, but it has also introduced some questions and tensions which will need to be monitored and managed as systems develop. These include questions about how the integrated care partnership (ICP) will interact with the integrated care board (ICB) and ensure a new and collaborative way of working across health, care and other partners in support of population health management; the management of conflicts of interest within ICBs, and the ongoing need to clarify the accountabilities of organisations working through systems. ICBs and ICPs – the two new statutory parts of ICSs – have only been in existence for a few months and will need time to embed and refine ways of working which help partners to navigate these questions.

ICSs have been formally established at a challenging time for the health and care system. The NHS is currently managing the impacts of a long and deep slowdown in funding growth, inflation eroding the real value of settlements, an adult social care system which does not have capacity to meet people’s needs, widespread health and care workforce shortages, and unusually high and sustained operational pressures. Ensuring leaders and boards can strike a balance between near-term priorities and long-term transformation is therefore important.

There are 42 ICSs which each have distinct local contexts, opportunities, and challenges. Population sizes, needs and characteristics vary substantially across the country, as do the make up and number of providers and partners within any given system, organisational histories and cultures. As such, the pace at which ICSs make progress on each of the four core purposes will differ.

ICSs embody a way of working together across services to better meet needs. They aim to blur the NHS purchaser/provider split and encourage joint ownership of system-wide opportunities and challenges. They are not, however, a multi-purpose solution to underlying problems which the NHS has been living with for many years and which warrant government attention: a mismatch between demand and capacity; a need to adequately address and fund workforce planning; a need to place the social care system on a sustainable footing; and a need to appropriately invest in prevention to ensure the health system is not unduly focused on treatment at the cost of earlier intervention.

National policymakers must establish a supportive framework to allow ICSs to maximise their potential and drive improvements on health outcomes, service efficiency, health inequalities and social and economic development. In particular, ICSs will need: the right oversight and accountability framework; stretching but realistic expectations of what they can deliver; adequate capital, revenue and workforce resource; and appropriate investment in the breadth of other public services which play a big role in contributing to broader population health.

ICSs’ progress to date

The NHS in England has embraced collaboration to better meet changing population health needs. This has been supported by the development of sustainability and transformation partnerships (STPs) and subsequently ICSs. Joint working took on new forms as partners responded to the unique challenges of the Covid-19 global pandemic. Many trust leaders report that relationships in their local health economies have improved over this period, and they are seeking to build on this now that ICSs have been placed on a statutory footing.

ICSs are developing from different starting points. They vary considerably, for example in geography, population sizes, prevalence of deprivation, as well as provider configurations and delivery structures. Some ICSs face greater challenges around primary care access, while others face greater backlogs of care across electives, mental health and community health services. This is compounded by differences in the extent of staff or funding shortages. Additionally, although collaboration has generally improved in recent years, systems vary in how well established joint working is. Local organisational histories and dynamics mean some systems have advanced further, faster in developing a culture of collaboration.

Trust leaders support the four core purposes of ICSs: 1) improve health and care outcomes; 2) tackle inequalities in outcomes, experiences and access; 3) boost productivity and value for money; and 4) support broader social cand economic development. Trusts are particularly positive about developing models of care that better meet the needs of people experiencing deprivation and/or health inequalities.

Measuring progress of integrated working at an aggregate level is not straightforward. NHSE and the Care Quality Commission (CQC) are adapting their ways of working and regulatory frameworks to reflect the new statutory arrangements. Looking ahead, it is expected that systems’ reporting on strategic plans – integrated care strategies, joint forward plans – will provide some insights into delivery progress. Additionally, places are expected to develop joint health and care outcomes frameworks from April 2023, which may help to illustrate how health outcomes are changing. But today, at this early stage in the development of statutory ICSs, understanding of delivery remains a work in progress.

Below we outline trusts’ views on the opportunities and tensions presented by the new statutory framework for ICSs, including the two-part structure of ICBs and ICPs, discuss the operational challenges services are managing today and their impact on the core purposes of system working, and identify the key questions national policymakers will need to act upon if ICSs are to fully realise their potential.

Opportunities associated with the establishment of statutory ICSs

ICBs have been created on geographies which were, in many cases, previously served by several clinical commissioning groups (CCGs). Populations vary between around 500,000 and 3 million, and most ICSs are planning and delivering services for populations in excess of 1 million people. Trusts are broadly supportive of moves to commission more services at scale, believing that it can help to streamline running costs, and support providers and commissioners to focus resources on service improvement. Within that broad framework, many trusts are also exploring place based, and neighbourhood arrangements where there is a need for services targeted at smaller population groups.

A prominent theme of national policy development around ICSs has been the role of non-statutory multi-agency partnerships at “place”, which are intended to lead much local planning, service transformation, and work to influence the wider determinants of health. Trusts generally support this emphasis, encouraging a focus on subsidiarity of decision-making and operational leadership. Place will be an important tier of activity, bringing together partners to work together to drive delivery and service change.

Provider collaboratives, partnerships of trusts (and in some cases other delivery partners like voluntary sector organisations), will be central to ICSs delivering on their ambitions. Many trusts are investing in developing their collaboratives and see them as a key vehicle to deliver improved care. Collaboratives’ initial work depends on local circumstances and priorities. A common focus is on addressing unwarranted variations in care and improving value for money in how trusts deploy their resources, for instance through advancing shared approaches to procuring goods and services and joining up other corporate functions.

Neighbourhood is an important tier of activity for many providers. Neighbourhoods are the focus for joining up many local services that people access regularly such as general practice, community pharmacy, wider primary care and voluntary sector organisations. Neighbourhood working – alongside joint work at place – presents opportunities to improve and join up the health and care services offered in communities.

ICBs are bringing together a number of NHS commissioning budgets which had previously been split across NHSE and CCGs. This amalgamation of budgets can bring a number of benefits: ICBs can be in a position to make more holistic decisions about resource allocation; this could support simpler commissioning between ICBs and trusts; bringing budgets together locally could – in theory – mean ICBs are incentivised to rethink resource allocations and shift resources towards prevention, which can be good for people and better value for money.

ICPs, statutory joint committees of ICBs and local authorities, have a remit to plan for broader health, care, public health and wellbeing needs of system populations. This design creates a statutory forum where the NHS will come into a critically important dialogue with stakeholders about the wider determinants of health, and could support a more joined up planning discussion across NHS, local authority and wider partners.

Tensions inherent in the design of statutory ICSs

While trust leaders are broadly supportive of the decision to create a statutory framework for ICSs, they also acknowledge that the design has given rise to some dilemmas which partners will need to navigate.

The composition of ICB boards, with a chair appointed by NHSE, who is accountable upwards and who controls appointment of non-executive directors, risks ICBs being NHS-centric in outlook when the system working agenda is inherently multi-sectoral. Some trust, local authority and primary care leaders are sitting on ICB boards through partner member roles. While these may support the bringing together of relevant expertise across sectors, they raise questions about conflicts of interest (or, at minimum, a perception of conflicts of interest) in particular: when ICBs will be commissioning services; and over how the trust’s corporate interest aligns with that of the ICB. Additionally, ICB boards have been constituted with an executive majority which may risk independent challenge and scrutiny being underpowered. Delays to the new provider selection regime, which is due to accompany the Act, and support commissioning decisions, may mean the current procurement rules (which remain in operation) do not align as clearly as possible with the new approach to prioritise collaboration within systems.

ICBs have taken on the roles and responsibilities of CCGs and will also play a role in oversight and performance management of local trusts. Trust leaders are keen to see ICBs further clarify how they will operate these multiple roles simultaneously – for instance, how they will balance oversight and support functions, and how they will contribute to addressing pressing operational priorities such as stabilising the urgent and emergency care pathway and supporting patient flow. The roles and responsibilities of ICBs raise related questions about the future of NHSE’s regional teams, given their functions around support, oversight and some commissioning functions, and the likely evolution of ICBs as they take on additional functions over time.

Place has been identified as a key tier of activity where much of the heavy lifting of integration work will be led, including between NHS and local government funded services such as public health and adult social care. The recent government integration white paper (February 2022) pointed to an aspiration to join up health and care planning arrangements at place through developing shared leadership arrangements, a shared set of health and care outcomes, and encouraging pooled or aligned budget arrangements. However, these arrangements overlay a statutory position that still does not easily support joined up care. The NHS remains nationally led and centrally accountable, with ICBs accountable via NHSE and the Department of Health and Social Care (DHSC); while local authorities remain accountable outwards to local electorates (and the Department of Levelling Up, Housing and Communities). Financial flows are similarly different between the two sectors.

ICSs are tasked with progressing both short and long term priorities. The four core purposes which NHSE has identified are long-term. At the same time, the NHS in England also has shorter term priorities to respond to, handed down from both DHSC and NHSE. There is often a tension between immediate and long term priorities, and sometimes misalignment between messaging from DHSC and NHSE. This can leave local leaders grappling with decisions about the relative priority they afford to the various agendas they are tasked with delivering on.

As the statutory regulator for quality, the CQC has been handed additional responsibilities in the Act to regulate and inspect system working (alongside existing responsibilities for inspecting services and organisations). CQC is navigating a change process as it develops regulatory frameworks and methodologies, including a single oversight framework, that will aim to gather robust and nuanced insight into care quality and partnership working arrangements, and command confidence among service leaders. Our recent survey of trust leaders, carried out in Spring 2022, found that trusts support CQC’s direction of travel but believe the methodologies need to continue evolving to reflect the changing realities of system working.[1]

Near-term operational challenges

ICSs have taken statutory form at a challenging time with a number of factors combining to create an environment which gives boards and operational teams limited bandwidth to focus on long-term change. Below we point to four key near-term pressures which characterise the operational context for ICSs, and which will influence how successful they will be on delivering on their core purposes.

Trusts are seeing a sustained level of high demand across the ambulance sector, in acute care and for mental health and community services The growing mismatch between demand and resource growth and workforce availability has been emerging for some time. In recent years, services have also had to grapple with elevated demand from people with Covid-19 related care needs. Today these challenges can be seen in the NHS being unable to maintain the service levels trusts would like to deliver against a range of operational targets, for example against ambulance response targets, A&E waiting time and several cancer waiting time standards. Mental health services are also in contact with record numbers of service users, and there is a backlog of around 1m people including children awaiting community services. While attention, understandably, must fall on tackling pressing operational issues, it risks curtailing leadership headspace to address longer term challenges.

The multi-year funding settlement granted to the NHS at the 2021 spending review compared favourably to some other public services. Yet the combination of a changing profile of demand and highly challenging efficiency expectations, since compounded by inflation, has left trust leaders managing constrained financial envelopes and severe operational pressures. In many cases, trusts are being asked to make substantial efficiency savings (which have not been risk assessed), with material uncertainty about their deliverability. Trusts are straining every sinew to recover care backlogs while a combination of factors continue to constrain their capacity to make faster progress. This in turn hits trusts’ ability to access elective recovery funding (ERF). Given this combination of factors, trusts foresee real difficulties in delivering financial balance across local systems.[2] Access to capital funding is also a concern for trust leaders, with already constrained capital envelopes being eroded by increasing prices.

Demand for social care is growing, partly as a result of demographic change. Yet there has been a large real-terms cut in social care funding between 2010/11 and 20202/21, leading to services which are unable to meet people’s needs effectively, high levels of unmet need, and high vacancy rates and turnover among staff. These challenges are contributing to both to failures to keep people well and independent, resulting in them needing more intensive health care, and to the large numbers of people who are medically fit for discharge spending more time in hospital, which is bad for patients and services as it reduces available capacity and leads to knock-on impacts across the system. Last year, the government unveiled a package of reform for adult social care services which, despite some welcome steps, has now been further delayed, and in any event, failed to put social care on a truly sustainable footing.[3]

The NHS workforce is over-stretched, partly due to chronic failures in national planning which heaps additional pressure on staff in post. There are around 132,000 vacancies in the NHS today, and trusts are spending around £7bn a year on temporary staffing to cover rota gaps. Existing staff are seeing their real take-home pay eroded by rising prices. A recent survey of trust leaders found 61% reporting an increase in staff sickness rates due to staff physical and mental wellbeing being compromised by due to cost of living pressures.[4] As well as impacting existing staff, the erosion of pay settlements raises further questions about the recruitment and retention outlook for NHS services.

Conclusion: what support ICSs need to progress the four key purposes

Trusts are optimistic about the potential for partnership working, and about their role in driving care backlog recovery and transformation within local systems, supported by the new national legislative and regulatory framework. They see opportunities to improve health outcomes, address inequalities in access and outcomes, boost productivity and contribute to local social and economic development. But they are also clear sighted about the range of challenges health and care services face and the difficult circumstances within which ICSs are seeking to establish themselves. In this context, trust leaders point to a number of areas – outlined below – where national policymakers can act to create an operating environment which support ICSs and trusts.

ICSs need an enabling and permissive framework which supports local leadership.[5] This involves: minimising changes to legislation and statutory organisations to create a stable environment; further work to clarify roles and responsibilities of the various constituent parts of systems, including ICBs and ICPs; a coherent and clear oversight and regulatory system which does not create unnecessary burden for trusts and services; and a set of focused national priorities which are oriented towards outcomes and which leave scope for systems and trusts to respond to local population needs. And, importantly, the behaviours and cultures of NHS national bodies will need to model an enabling ethos and support local leaders and organisations to work in a way that is responsive to their local contexts and population health needs.

Trusts leaders’ experience of leading change reinforces that while integrated models of care can deliver improvements for patients and staff, they take time to implement. Place-based partnerships and provider collaboratives are developing from different starting points, with many recently established, and will lead much of the operational work of integration and improvement. In this context, national bodies can support ICSs by making sure operational expectations balance constructive stretch and realism.

The health and care system is facing a number of challenging operational pressures – across acute, urgent and emergency, community, mental health, and primary care services. These are driven by a range of factors, including a decade of tight funding settlements for health and care services and long-standing gaps around infrastructure investment and national workforce planning. If ICSs are to address these challenges and restore operational performance to levels leaders aspire to, they will need resources for health and care services – spanning both revenue and capital – which recognise changing population needs. This should include a funded, long-term workforce strategy for health and care services. Additionally, national policymakers need to recognise that the ability of health and care services to work in partnership across local systems depends on adequate resourcing across the range of services, including community services, primary care, and social care.

There is a range of evidence today illustrating population health is influenced by a multiplicity of factors which largely sit outside the control of health and care services. Trusts, ICBs and other partners have an important role to play in addressing health inequalities and preventing ill health. But their ability to make long-term impact will also depend on appropriate investment in a range of public services – including housing, criminal justice, education, transport, public health – which shape the communities people live in and can support them to lead healthy lives.

October 2022