Identifying next steps and key priorities for integrated care systems
On 24 March 2022, we hosted a roundtable on next steps and key priorities for integrated care systems (ICSs) supported by Hill Dickinson LLP. The session engaged leaders from a range of ICSs in an open discussion on the pace and scale of system development.
Colleagues shared perspectives on their experience to date and the priorities for developing high-performing system boards within operating frameworks that are responsive to local needs. The group identified key challenges and opportunities to deliver impact in the first 12 months of establishment and beyond.
This article captures the key points from the discussion and suggests a set of questions for integrated care board members to consider.
Summary
- Attendees expressed a clear commitment to delivering on the principle of subsidiarity, with clear conditions to be met by place-based teams and provider collaboratives.
- There are exciting opportunities for systems to develop a culture of challenge and support, which facilitates practical learning between places and innovation.
- The focus on improving outcomes is the fundamental driver for system working, with the need for system partners to navigate variable levels of pace and maturity in achieving this.
- Workforce challenges are recognised as the major strategic risk, with systems open to innovative and creative approaches as part of the next stages for ICSs.
Priorities for integrated care systems
There was a strong level of consensus among attendees on the direction of travel for ICSs, with support for more collaborative ways of working and place-based approaches, which have been developing for a number of years across the health and care sector. This was reflected in the experience of the group in relation to place-based leadership and provider collaborative arrangements, as well as wider governance and establishment issues associated with integrated care partnership (ICP) and integrated care board (ICB) membership appointments.
The demanding operating context was recognised, in particular the sector-wide workforce challenges and constraints associated with systems working from a position of financial deficit. These dynamics were framed as important strategic risks to the transformation agenda which colleagues are seeking to deliver, and which emphasise the importance of the NHS forming a different and closer relationship with local authority and other system partners.
The following four areas were highlighted throughout the discussion:
- System culture
- Approaches to delegation and subsidiarity
- Strengthening the focus on outcomes
- Workforce
System culture
The roundtable discussion emphasised the fundamental role that culture will play in the success of ICSs, and the need for system partners to work together to foster inclusive and supportive culture within the work of systems. Shifting from a focus on individual organisations to more population-based approaches was recognised as a cultural change not to be underestimated.
ICBs have an important role in developing a system-wide culture of challenge and support. The group discussed the challenge for ICB members of understanding the cultural changes that may be needed, and of recognising the inherent biases that all colleagues will have. It was felt that highlighting and assessing these biases is a valuable exercise in system development, which can identify shared needs and the wealth of learning available across all partners. A number of attendees articulated that they were seeing 2022/23 as a transitional year, with a clear requirement for system development and transformation to be achieved in a safe way.
An important part of this element of the discussion was about how to cultivate a learning culture, so that parts of any system see benefits in learning from each other. The group agreed that it would be important to avoid a reliance on rigid ‘top-down’ learning frameworks, but instead to develop and nurture ‘horizontal’ learning across places, and across systems and regions. This sentiment echoed a key point outlined by Professor Chris Ham in his recent report commissioned by the NHS Confederation:
'ICSs themselves should operate on the basis of subsidiarity and foster a culture of innovation and improvement in the neighbourhoods, places and organisations that make up systems.'
Approaches to delegation and subsidiarity
The group discussed various approaches to delegation and subsidiarity in relation to ICSs, and the potential implications for system objectives. It was agreed that systems could decide to operate a delegated model, with the ICB role to monitor performance, manage allocation, broadly enable decision-making at place and provider collaborative level. Systems could also decide to hold more decision-making at ICB level in the immediate term, with this being allocated out to place and provider collaborative level over time.
Colleagues recognised the importance of the principle of subsidiarity, with a couple of conditions identified for this principle to be implemented effectively in systems:
- Delegation for a purpose – allowing the ICB to have clarity on the plan for system partners to achieve the agreed outcomes.
- Good governance – ensuring local decision making is empowered by robust assurance arrangements.
The group agreed that the shared ambition was to achieve a delegated model, with decision-making powers devolved to place leaders. However, given the nascent state of structures and relationships at place and collaborative level in many areas, the group highlighted that it was crucial for ICBs to be clear which level of delegation is appropriate currently and why this course is being taken. This will allow system partners to build and agree clear plans.
It was felt that the pace of delegation within systems could be informed by places meeting the two above conditions sufficiently. This will mean that certain place-based partnerships within systems will take on delegated authority at different speeds, and the roundtable group wanted to encourage areas that are ready to go further faster, and for other parts of the system to learn from them. This approach can recognise a shared development journey with variable progress. How to best handle this kind of variation in maturity and ambition across different places was seen as an important question for ICBs to consider and plan for.
Strengthening the focus on outcomes
A central theme of the roundtable discussion was patient and public focused decision making. Attendees recognised that any particular approach to subsidiarity is only part of the overall picture in aiming to achieve improved outcomes for local communities. The group discussed the need for systems to address capacity and skills requirements to deliver this outcomes-based focus. The Canterbury Health System was mentioned as an example of a system that effectively assessed the enablers for change as a means of supporting system partners to deliver integration.
As part of this ambition to strengthen the focus on outcomes, the group recognised the impact of COVID-19 in highlighting weaknesses in the health and care system, and in particular the stark health inequalities which systems are seeking to address. Attendees discussed the opportunity for ICB members and system leaders to foster and support social innovators to drive transformation through partnership working.
In this way, attendees agreed that system working is not about demonstrating a neat way of organising the same approaches, but instead about how system partners are connecting with people and improving outcomes for communities. Incorporated within this discussion was the importance of taking the opportunity to amplify the voices of both staff and community groups which have traditionally been less heard.
Workforce
The theme of workforce was also referenced throughout the discussion. Recognised as the major strategic risk facing health and social care, workforce recruitment, retention and resilience is a wider issue for the whole health and care system. The group discussed these issues, and while establishing the scope for any individual system to impact on this sector-wide shared challenge will be difficult, and further exacerbated based on regional contexts, colleagues unsurprising placed workforce issues as a key priority for ICSs.
Alongside efforts to support staff wellbeing, attendees discussed the opportunity to think creatively in terms of workforce allocation, and how clinical commissioning group staff might be best used to support the development of place-based teams and collaborative working with primary care and other partners.
Similarly, there were ambitions expressed within the discussion to continue to shift the workforce impact of aligned system partners, such as regulators. Colleagues agreed that they did not want to see a burdensome regulatory approach, with a more facilitative method viewed as adding greater value. Workforce collaboration to assess culture, partnership working and leadership was seen as an important opportunity, which can better use peer learning type approaches.
Questions for ICB members to discuss
- With an understandable need to a focus on system governance and establishment issues, how are ICS leaders ensuring they have sufficient bandwidth to engage with broader issues?
- What are the accountability and risk appetite implications for ICBs and ICPs, and for system partners individually in relation to strategic objectives?
- What are the accountability expectations of NHS England and NHS Improvement regional and national teams, and their likely working relationships with ICBs?
- What different skills are needed for ICB members as opposed to a Trust board or other board roles? How are colleagues fostering a different approach in terms of ‘system leadership’ skills?
- How are board members assessing the consistent and shared approaches among ICSs, alongside the unique needs of each system?
- How are ICSs developing a collective voice as a system in relation to anchor approaches, and what are the implications for ICBs and ICPs?
Hill Dickinson is advising a number of ICBs and place-based Pprtnerships on their initial set up and structuring issues. Please contact Rob McGough or Esther Venning if they can be of assistance.
