Overview
Integrated Care Systems (ICSs) were legally established on 1 July 2022 based on the Health and Social Care Act 2022, although operating in shadow form for some time beforehand. A review of their oversight and governance arrangements so quickly after their establishment may seem rapid – but supporters of the new arrangements sense this is the best opportunity to really change the way in which residents experience health and care and to truly invest in prevention across the broad spectrum of partners – of which Local Government, with its knowledge and connection to communities, is critical.
The findings of this rapid review should be welcomed by boroughs and ICSs as a positive step in refining and embedding the cultural shifts in behaviour that can support the reality of integrated care.
What are Integrated Care Systems?
ICSs are the new structures designed to bring NHS services and social care closer together and working in partnership to:
- improve outcomes in population health and healthcare
- tackle inequalities in outcomes, experience and access
- enhance productivity and value for money
- support broader social and economic development.
There are five ICSs in London, out of 42 across England, all were established on 1 July 2022.
Integrated care systems are partnerships that bring together local government, the NHS, social care providers, voluntary, community, faith and social enterprise (VCSFE) organisations and other partners to improve the lives of people who live and work in that area, in line with their four core purposes outlined above. Each ICS includes a statutory Integrated Care Partnership (ICP) and an Integrated Care Board (ICB).
The ICP is a statutory committee jointly formed between the ICB and the relevant local authorities within the ICS area. The ICP brings together the broad alliance of partners and is responsible for producing an integrated care strategy and Joint Forward Plan on how to meet the health and wellbeing needs of the population in the ICS area.
The ICB is the statutory NHS organisation responsible for bringing NHS and other partners together to plan and deliver integrated health and care services and accountable for the finances and performance of the local NHS as a whole.
ICSs are due to publish their Joint Forward Plan as to how they will meet the four core aims by 30 June 2023.
When was the review initiated?
The review was commissioned by Health Secretary Steve Barclay MP in October 2022. The Rt Hon Patricia Hewitt, a former health secretary and current Chair of Norfolk and Waveney NHS ICB, was invited to conduct the review.
To get the views and expertise of ICSs, local government, the NHS, the voluntary sector, patient and service user representatives and other subject experts including in academia, government departments and relevant thinktanks a consultation was launched on 13 December 2022 and closed on 9 January 2023. The questions posed in the consultation are at appendix 1.
What was the scope of the review?
The review was designed to consider how the oversight and governance of integrated care systems (ICSs) can best enable them to succeed, balancing greater autonomy and robust accountability with a particular focus on real time data shared digitally with the Department of Health and Social Care, and on the availability and use of data across the health and care system for transparency and improvement. It covered ICSs in England and the NHS targets and priorities for which integrated care boards (ICBs) are accountable, including those set out in the government’s mandate to NHS England.
In particular it was asked to consider and make recommendations on:
- How to empower local leaders to focus on improving outcomes for their populations, giving them greater control while making them more accountable for performance and spending.
- The scope and options for a significantly smaller number of national targets for which NHS ICBs should be both held accountable for and supported to improve by NHS England and other national bodies, alongside local priorities reflecting the particular needs of communities.
- How the role of the Care Quality Commission (CQC) can be enhanced in system oversight.
What were the findings of the Hewitt Review?
The review, published on 4 April, identified six key principles, that will enable the context to be created so ICSs can thrive and deliver.
These are:
- collaboration within and between systems and national bodies
- a limited number of shared priorities
- allowing local leaders the space and time to lead
- providing the right support
- balancing freedom with accountability
- enabling access to timely, transparent and high-quality data.
The review was conducted respecting the four core purposes enshrined in law for ICSs to deliver, namely:
- improve outcomes in population health and healthcare
- tackle inequalities in outcomes, experience and access
- enhance productivity and value for money
- support broader social and economic development.
The headline conclusions are:
From focusing on illness to promoting health
- Delivering these principles will require genuine change in how the health and care system operates.
- This will require a shift in resources - the share of total NHS budgets at ICS level going towards prevention should be increased by at least 1% over the next 5 years.
- It will also require cross-governmental collaboration to embed a national mission for health improvement and the establishment of a new Health, Wellbeing and Care Assembly
Delivering on the promise of systems
- To do this effectively, national and regional organisations should support ICSs in becoming ‘self improving systems’, given the time and space to lead - with national government and NHS England significantly reducing the number of national targets, with certainly no more than 10 national priorities. Subsidiarity at place, system, regional and national levels – should be encouraged. The NHS currently one of the most centralised health systems in the world, and ICSs is an opportunity to rebalance this.
- The most effective ICSs should also be encouraged to go further, working with NHS England to develop a new model with a far greater degree of autonomy, combined with robust and effective accountability.
- The availability of timely, transparent and high-quality data must be a priority, and NHS England and the Department of Health and Social Care (DHSC) should incentivise the flow and quality of data between providers and systems. The Federated Data Platform can provide the basis for a radical change in oversight, to replace situation reports (SITREPS), unnecessary and duplicative data requests.
- Both the Care Quality Commission (CQC) and NHS England will continue to have a vital role to play in oversight and accountability, but they should ensure that their improvement approaches are as complementary as possible, and complementary to peer review arrangements between systems.
- It will be vital to ensure the right skills and capabilities are available to ICSs as both systems and national organisations manage through a period of challenge for the nation’s finances.
Unlocking the potential of primary and social care and their workforce
- Given the interdependence of health and social care, the government should produce a complementary strategy for the social care workforce.
- More should also be done to enable flexibility for health and care staff, both in moving between roles and in the delegation of some healthcare tasks.
- National contracts present a significant barrier to local leaders wanting to work in innovative and transformational ways. The report recommended that work should be undertaken to design a new framework for General Practice (GP) primary care contracts, as well as a review into other primary care contracts. Work also needs to be done to ensure that there is the flexibility to competitively recruit and train more specialists in fields such as data science, risk management, actuarial modelling, system engineering, general and specialised analytical and intelligence.
Resetting the approach to finance to embed change
- Instead of viewing health and care as a cost, all partners need to align, locally and nationally, around the creation of health value.
- NHS funding remains over-focused on treatment of illness or injury rather than prevention of them and ICS partners struggle to work around over-complex, uncoordinated funding systems and rules in order to shift resource to where it is most needed. Instead, it is important to identify the most effective payment models, nationally and internationally, with an aim to implement a new model with population-based budgets, which will incentivise and enable better outcomes and significantly improve productivity.
- There should also be a review into the NHS capital regime to address the inflexibility in use of capital and the layering of different capital allocations and approvals processes. NHS England should also ensure that systems are able to draw upon a full range of improvement resources to support them to understand their productivity, finance and quality challenges and opportunities.
How is this likely to impact upon the health and care landscape in London?
In her foreword, Hewitt notes that “ICSs bring together all the main partners - local government, the voluntary, community, faith and social enterprise sector, social care providers and the NHS - in a common purpose…. This report shows how they are already making a difference and explains what needs to happen next to accelerate that progress.”
Some areas of the report that may be helpful for place-based partnerships, and those involved with ICPs – in particular:
- Local Government and Health as ‘equal partners’ are given the time and space to lead to meet the locally agreed priorities and targets in their joint forward plan. The review endeavours to create the confidence in Government that although each ICS is different and some are more mature than others, they are all on a positive trajectory. Hewitt also recommends a small number of national targets that have equal weight with locally co-developed priorities or targets.
- Prevention and the wider determinants of health is a strong theme of the review with clear recommendation around increasing the current levels of investment. Also, delivering cross-departmental working, aligning budgets to agreed priorities and joining up of data at local and system level so population health analysis becomes population health equity through targeted investment.
- Self-improving and peer learning within and across systems building on the structures that local government already uses – in recognition of their success.
- System leadership and development to increase management resilience to drive overall capacity and capability through a health and care workforce. Recommending a national workforce strategy for social care alongside the one promised for the NHS.
Commentary
The Hewitt Review makes 36 recommendations in total – many of which ICSs are in a position to adopt without further guidance. The four areas highlighted as particularly significant for local government are: being seen as equal partners in the ICS; greater investment by all partners in prevention of ill-health; supporting self-improvement and peer learning as ICSs mature; and, improving resilience through system leadership.
The findings of this rapid review should be welcomed by boroughs and ICSs as a positive step in refining and embedding the cultural shifts in behaviour that can support the reality of integrated care.
Appendix 1: consultation categories and questions:
Empowering local leaders
Question 1
Please share examples from the health and care system, where local leaders and organisations have created transformational change to improve people’s lives.
This can include the way services have been provided or how organisations work with residents and can be from a neighbourhood, place or system level.
Question 2
Do you have examples where policy frameworks, policies and support mechanisms have enabled local leaders and, in particular, ICSs to achieve their goals?
This can include local, regional or national examples.
Question 3
Do you have examples where policy frameworks, policies, and support mechanisms that made it difficult for local leaders and, in particular, ICSs to achieve their goals?
This can include local, regional or national examples.
Question 4
What do you think would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals?
Question 5
What policy frameworks, regulations or support mechanisms do you think could best support the active involvement of partners in integrated care systems?
Examples of partners include adult social care providers, children’s social care services and voluntary, community and social enterprise (VCSE) organisations. This can include local, regional or national suggestions.
National targets and accountability
Question 6
What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system level decision-making?
Question 7
What mechanisms outside of national targets could be used to support performance improvement?
Examples could include peer support, peer review, shared learning and the publication of data at a local level. Please provide any examples of existing successful or unsuccessful mechanisms.
Data and transparency
Question 8
Do you have any examples, at a neighbourhood, place or system level, of innovative uses of data or digital services?
Please refer to examples that improve outcomes for populations and the quality, safety, transparency or experience of services for people; or that increase the productivity and efficiency of services.
Question 9
How could the collection of data from ICSs, including ICBs and partner organisations, such as trusts, be streamlined and what collections and standards should be set nationally?
Question 10
What standards and support should be provided by national bodies to support effective data use and digital services?
System oversight
Question 11
What do think are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?
Question 12
What type of support, regulation and intervention do you think would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues?
Additional evidence
Question 13
Is there any additional evidence you would like the review to consider?