The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. Our recent research has used financial analysis, legislative work, roundtables and wider research across the NHS and social care to examine the current position of the new integrated care structures created by the 2022 Health and Care Act and the challenges they face. This submission outlines the current situation as we understand it, and summarises key considerations which will affect how able ICSs are to deliver the core stared objectives outlined by the Committee.
Key points
The establishment in statute of Integrated Care Boards with associated Integrated Care Partnerships (together known as Integrated Care Systems, or ICSs), alongside the repeal of certain elements of the Health & Care Act 2012 relating to competition, has addressed a number of the legal hurdles which were previously thought to cut across effective partnership working. However, the establishment of new governance structures does not in itself deliver the outcomes which ICSs are intended to achieve. There are several practical and cultural obstacles still to be surmounted by local and national leaders.
Although ICBs take on the functions previously delivered by Clinical Commissioning Groups, which have now been dissolved, individual provider organisations will remain separate bodies in their own right, with their own Boards and statutory duties. Although those include a duty to co-operate, the likelihood of competition between organisational priorities and accountabilities seems high.
ICBs and ICPs are not the only new form of partnership being established. The simultaneous development of multiple partnership structures create complexity which may be compounded by uncertain goals and misaligned incentives:
There is a very real risk that resource constraints – whether revenue, capital or capacity – limit the ability of ICBs, ICPs and ‘places’ to implement change and in particular to develop multi-disciplinary working, that is, the design might be right but the ability to act is missing. Local leaders are in effect being asked to redesign their jumbo jets not only whilst they are flying, but at the point where their engines are starting to fail. Although it is clear that local leaders understand the long term challenges they are being asked to address, the difficulties in maintaining service in the short term, in the face of workforce shortages and a lack of investment in capital infrastructure, are naturally taking precedence.
Alongside the structural complexities and constrained resources, the establishment of ICBs and ICPs represents a significant culture shift not only for local NHS leaders but also for leaders at the centre, up to and including national politicians. As Sir Gordon Messenger noted in his recent review of leadership in the NHS, “The sense of constant demands from above, including from politicians, creates an institutional instinct, particularly in the healthcare sector, to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user.”
There remains a risk that embedded culture and behaviours and inter-organisational power dynamics act against the development of collaborative service delivery and planning. This relates to both relationships and ways of working between the centre and place (eg, NHS England and place-based leads), as well as across teams and organisations within a place (eg, acute and primary care organisations or NHS and social care).
The 2022 Health and Social Care Act gives ICBs a duty to promote integrated health and social care services where they consider this would:
In addition to these assumed potential benefits, multiple other objectives relating to integration have been assigned to ICBs and ICPs, amongst them:
However, there is as much disagreement about how each of these claimed benefits might be measured as there is over whether or not there is evidence to support claims that integration will produce them.
Defining, measuring and evaluating integration is not straightforward, and limitations of existing data constrain our ability to describe and measure the impact of change. Without a clear understanding of the baseline position, it will be difficult to assess the impact of ICBs and ICPs on the four objectives set out.
Service quality and patient satisfaction
Our research examining the performance across the four countries of the United Kingdom shows that over 20 years of reforms focused on integration have translated into at best modest improvements for patients in each country, which raises important questions about what integrated care can realistically achieve. Effective collaboration relies not only on legal frameworks but also on having sufficient resources, incentives, regulatory and outcomes frameworks – and consistent leadership and cultures across health and social care.
There is already a significant risk of objective and expectation overload as ICBs become the default tier in the system for the performance management of local NHS providers. Although strategically it can be argued that this is an enabler for long term success, as noted above it is much more likely that dealing with short term performance issues will sap management capacity.
Integrated care reforms have consistently been undermined in the UK through a mismatch between the scope of proposals and what they are intended to achieve. It would be unwise to expect that place-based systems are able to produce cost savings or improve health outcomes –at least in the short-term– though they may help improve patient and service user experience. There is also limited evidence that integration has encouraged more money to flow to social care and prevention – largely due to the context in which integration is happening and broader government policies that influence the distribution of resources across health and social care, and the ability for people to lead independent, healthy lives.
It is also important that the outcomes against which integration is measured are reflective of what it is intended to achieve. Overreliance on hospital-based measures has inhibited change within community and social care services. And if we intend to create meaningful change for service users, then more attention needs to be paid to these services and the experiences of those who use them.
Healthcare inequalities
The 2022 Health and Care Act gives Integrated Care Boards duties to reduce inequalities “between persons... ability to access health services” and “between patients with respect the outcomes achieved for them by the provision of health services”.
The wording on the duty is near-identical to the previous equalities duty for Clinical Commissioning Groups, save that the duty regarding ability to access services now applies more widely to “persons” rather than “patients”.
Forthcoming work by The Nuffield Trust for the Greater London Authority found[1] that over the last decade, NHS efforts to address inequalities in care access in particular has tended to focus not on the NHS equalities duty, but rather the 2010 Equalities Act. That legislation, supported by ample case law, includes a framework of 9 “protected characteristics” (including sex, ethnicity, age, disability and sexuality) which are often the de-facto lens through which the NHS duty has been interpreted.
While it is the case that many of the groups in effect provided protections by the Equality Act are groups experiencing poorer levels of healthcare access and outcomes, the framework excludes socio-economic deprivation, which is the pre-eminent driver of both health and healthcare inequalities, not least because it so often overlaps with other forms of social exclusion and marginalisation.
Although NHS England has adopted a strengthened and more proactive approach to health and healthcare inequalities experienced by socio-economically deprived social groups since the pandemic – particularly through its CORE20 Plus 5 programme – it is not clear how sustained this approach will be. The 2022 Act does not appear to put socio-economic drivers of health and healthcare inequalities on the same statutory footing as inequalities associated with the 2010 protected characteristics.
Healthcare efficiencies
Although in theory ICBs bring with them opportunities to improve both technical and allocative efficiencies these may be limited in practice by the fact individual provider organisations – with their own accountabilities and requirement to balance their books – will continue to exist alongside the ICB structure. It would be naive to assume, for instance, that a large provider trust will necessarily be willing to reduce its footprint in a given service area in the interests of ICB-level allocative efficiency, particularly if that may lead to a material loss in income for the organisation.
At the same time, although individual NHS trusts and Foundation Trusts will continue to exist as legal entities, much of the previous financial framework designed to drive efficiencies in the provider sector has been removed, undermined or diluted by the new framework. In particular, the incentive for provider trusts to reduce their unit costs has been substantially undermined by the imposition of capital spending controls over providers, which replaces the prior freedom for Foundation Trusts to generate financial surpluses for future capital investment. It is not clear what alternative mechanism for driving efficiencies is intended to replace this earlier framework.
There are significant exogenous factors which mean that however well-established ICBs and ICPs are, and however good their leadership, success will be hard to achieve. At a national level, the health and care system is experiencing the most serious combination of finance, workforce, and performance challenges of any time in its history. This, coupled with the wider social challenges relating to, for example, the cost of living crisis, mean that the actions taken by any individual ICB or ICP will be limited in their effect.
Workforce
Integrated Care Systems have come into existence at a particularly challenging time for the health and social care workforce. In fact, our view is that addressing workforce issues will be a key initial test of whether they can enable their constituent bodies to work, as intended, in partnership. As outlined below, they should have a role in ensuring the recruitment and retention of a diverse and inclusive workforce but their workforce responsibilities should not end there.
Given the challenges in meeting government workforce commitments it seems inevitable that overseas recruitment will be required, at least in the short term. Many NHS Trusts have managed to recruit large numbers of nurses from overseas, but some services and sectors including smaller social and primary care providers can currently struggle given the upfront investment required.
In relation to attracting, supporting and retaining a diverse workforce, we have recommended that every system should follow the lead of some areas in having a substantive equality and diversity lead, to help provide enhanced specialist support for employers. They should, in our opinion, also consider pooling resources to undertake evaluations of key diversity initiatives as well as provide leadership on inclusive recruitment:
“Integrated care system people boards should review their current approach to recruitment and work collectively to understand their local labour market, their collective vacancy gaps and their ‘offer’ for entry into careers for local people, particularly those furthest from employment, to support economic recovery and improve local health inequalities. Specifically, all areas should publish ‘preparation for work’ programmes – including work experience and pre-employment initiatives – jointly agreed with relevant partner organisations such as colleges and universities. Progress should be measured to ensure participation from all groups in the local community.”
Notwithstanding these recommendations for individual ICBs, we continue to call for a fully costed workforce plan covering both health and social care to be published as a matter of urgency.
Finance
ICSs have been introduced more than a decade into an ongoing period of tight NHS finances and inherit a social care system which is chronically underfunded. Spending plans to 2024/25 mean average annual increases in total health care spend per person, after adjusting for age, of 0.5% between 2009/10 and 2024/25, compared with annual increases of 5.7% the decade leading up to 2010. This has repeatedly seen NHS trusts set efficiency targets which prove to be unachievable, resulting in raids in budgets for investment and improvement. Even before the current high levels of inflation, ICBs inherited this financial mandate and were expected to find over £5 billion in savings in their first year, far above the historically deliverable level.
Wider Social Value
Given the size and scale of the NHS’s economic footprint as both one of the largest employers and biggest spender in local areas, the NHS influences the social, economic and environmental conditions of local communities. There is hope that ICSs will make it easier for the NHS and local partners like housing, education and employment to establish common goals and work together to improve the socioeconomic conditions of health local communities. This might include through supporting fair pay and improving working conditions in local areas, shifting more spend locally or to ethical organisations, reducing the NHS’s carbon footprint. However, the scale of the challenge and the size of the ask in the current climate should not be understated.
October 2022
[1] Report to be published November 8th