Written evidence submitted by the Royal College of Psychiatrists (ICS0068)

Integrated Care Systems: autonomy and accountability

Bringing together NHS organisations, local authorities, voluntary community and social enterprises and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas offers a great opportunity to improve mental health support.

We are pleased that the Health and Social Care Act stated that at least one member on an ICB must have knowledge and expertise in mental health services, however we are concerned whether this will lead to meaningful prioritising of mental health in practice.

We are concerned what the recent changes may mean for accountability, especially when we see examples of poor care both nationally and locally.

From July 2022, ICSs became the new intermediate tier for the health system in England, with four broad aims:

-         improving outcomes in population health and health care

-         tackling inequalities in outcomes, experiences and accessing services

-         enhancing productivity and value for money

-         helping the NHS support broader social and economic development.

Each ICS includes and Integrated Care Board (ICB), responsible for developing a plan for meeting the health needs of the population. For ICSs and ICBs to be truly successful, they need to embrace the key elements of partnership working, including openness, shared goals and values between all parties involved.

Many ICBs are developing the Mental Health Provider Collaborative model locally, which supports transformation at scale on behalf of the ICB. It is great to see such innovative developments taking place locally, especially the increased focus on Third Sector partners, patients and families, and Local Authorities.

In the Autumn Statement, the Chancellor tasked former health secretary, Patricia Hewitt, on advising on how to make sure the new integrated are boards (ICB) operate efficiently with appropriate autonomy and accountability’

• We welcome more integrated models of community care. Too often, people with severe mental illnesses spend too much time in inpatient care or fall

through the cracks altogether because their needs stretch across mental health, physical health, social care and other services.

• ICSs have an important role in providing strategic direction and this should include oversight of the entire mental health pathway for adults, children and young people across the system. This includes preventative and early interventions services, primary care, social care, housing, access to digital provision and specialist mental health services. This would help join up systems and pathways, reducing barriers to care and allowing more people to access care that meet their needs, including through reducing out of area placements.
• ICSs present a particular opportunity to carry out well-evidenced and large- scale public mental health interventions that are equally relevant across the whole system, which will be more cost-effective when delivered on this scale.
• ICS must have due regard of local workforce availability and develop system- wide pans to address current and future workforce supply locally.
• ICS also present an opportunity for better targeted investment in mental health infrastructure,
• With ICBs commissioning services we believe that mental health services potentially will be patient and client centred, meeting their needs and personalised care.
• While welcome more local autonomy, we are concerned that in practice this can lead to mental health being side-lined, as ICBs focus on a number of other key priorities.
• There is still not parity between mental and physical health and failure to prioritise mental health could lead to the gap widening.

• We think it is still to too early to have a clear idea on how integrated care strategies are being developed.
• There is the potential for ICSs to be overwhelmed by elective-recovery work, addressing the challenges across the urgent and emergency care pathway, as well as pressures in primary care. A key question is whether these relatively new organisations will be able to cope.
• Where there is mental health capability within ICSs, we are concerned about whether they have the bandwidth to think about mental health at the moment beyond being a part of the challenges above. For example, only considering how to address mental health patients in ED who are waiting longer than 12 hours or thinking about mental health as a part of solution on how to improve ambulance response times.

Representation on ICBs             

• We campaigned for and support the commitment that ICBs are legally required to have at least one person with knowledge and expertise in mental health services. We believe having this representation is vital for moving towards parity of esteem.
• We are concerned though that representation is not enough to ensure positive change for mental health services. Systems must be put in place to ensure mental health is considering meaningfully in integrated care strategies.
• It is critical that mental health representation understands the challenges surrounding delivery of services, including clinical pathways and parity of mental and physical health, for those in local communities with SMI as well as the wider public mental health messaging.

• ICSs should have Mental health reflected as a top priority, with full programme delivery supported and tracked at ICS board level.
• NHSE should review each ICBs five-year systems plan annually to be assured that:
• it meets the ambition set out by their ICS
• has a clear plan to improve mental health and wellbeing outcomes in population health and healthcare
• tackles inequalities in mental health and wellbeing outcomes, experience and access to care and support o reflects the national priorities and ambitions of the NHS LTP for Mental Health and the forthcoming cross-government mental health and wellbeing plan
• sufficiently takes account of how they will commission specialist mental health services previously commissioned by NHSE, and
• aligns clearly with the national mental health workforce plan and is realistic and deliverable locally.
• NHSE should use the findings from these annual assessments to provide tailored support and guidance to ICBs.
• ICSs should ensure that Integrated Care Strategies drive a coordinated public mental health approach across all parts of the system. Guidance should be clear on how the system itself can be designed to prevent poor mental health and support good mental health.
• ICS leaders should develop a system-wide outcomes framework, including mental health and wellbeing outcomes, which defines the partners’ collective ambition for improving outcomes for people living in the area, which should be then used to monitor performance against the outcomes framework annually.
• ICS leaders should follow National Collaborating Centre for Mental Health guidance and standards to enable the delivery of high-quality, equitable mental health care standards, workforce competences and quality improvement initiatives to enable the delivery of high-quality, equitable mental health care

Accountability             

• We are concerned that there may not be clear accountably for ICS’s. We would be keen to get clarity on who is responsible between NHS England and individual ICBs when there are examples of poor care, on a local and on a more systematic level.

Dec 2022