Parity of power, diversity of contribution

Although all integrated care systems (ICS) are different (for reasons of history, geography, politics and relationships), the purpose of these blog posts is to suggest what sociologists refer to as an ‘ideal type’; a kind of generic model for an ICS even though no actual system will precisely match this model.

The first post explored the relationship between integrated care partnerships (ICPs) and integrated care boards (ICBs) and suggested that more work needs to be done in defining the roles and responsibilities of ICPs. This post explores some key principles that might be applied to the relationship between ICSs (particularly ICBs) and provider collaboratives.

This is important for several reasons: there often appears to be a lack of clarity about the purposes of forming collaboratives; there is not always a sufficient distinction between the rationale for horizontal, vertical and hybrid collaboratives; there may appear to be some duplication between the roles and aims of collaboratives; and it has been suggested that forming strong collaboratives is way for providers to limit the influence and capacity for challenge of ICBs.

So, what might be some key design features of the relationship between ICBs and collaboratives?

Provider collaboratives must work in partnership with ICBs to develop complementary roles and governance

Though the core founding members of the new ICPs will be the ICB and local authorities, ICP membership will be broad and inclusive, with an important role for provider collaboratives as a core partner critical to the successful delivery of integrated care. Both ICBs and provider collaboratives should act as partners in influencing the strategy of health and care systems for their populations. Together they can use the permissiveness of the legislation to make their contribution to the four core aims of ICSs:

• Improving population health and healthcare.
• Tackling unequal outcomes and access.
• Enhancing productivity and value for money.
• Helping the NHS to support broader social and economic development.

When facing the common enemy of COVID-19, we have seen innovation in collaboration on an unprecedented scale. To summon the same energy to address recovery and the long-term challenges of population health, we need to sustain and deepen that sense of purposive collaboration. That cannot simply come from those whose involvement in ICPs is mandated in legislation. Each ICS arrangement must capture the skills, expertise and passion of place, provider and commissioner, with mandatory contributors sharing power with those best equipped to meet population health outcomes.

Effective structures will see the ICB planning, assuring and allocating resource to the NHS on behalf of the ICS, with provider collaboratives establishing mechanisms for delivery. Perhaps this reads as a worrying callback to the decades of competitive tendering process through a provider/commissioner split? Instead, this should be about clarity of purpose with equitable distribution of power. The ICB is not a traditional arms-length commissioner or old-style health authority, telling provider collaboratives what to do or not do.

The ICBs are stewards on the integration journey, guiding its partners towards reduced health inequality and greater upstream intervention

The board should be an expert partner focused on the commissioning part of a system strategy, working alongside the provider partners committed to jointly agreed system goals.

The ICBs are stewards on the integration journey, guiding its partners towards reduced health inequality and greater upstream intervention. They should catalyse improvement and innovation, take on the wicked issues that present for the system, and facilitate effective monitoring of progress towards key strategic objectives on behalf of the ICS, committing to support the system to bring about improvements

ICBs negotiates the relationship between provider collaboratives and NHSEI through a system-by-default approach

Mature and well-developed relationships between NHS England and NHS Improvement (NHSEI) and ICSs involve a great deal of delegation of responsibility to ICB leadership, as ICBs are best placed to understand whether provider collaboratives are delivering on system ambitions. If we expect leaders to establish a framework of mutual accountability as part of their integrated approach, the centre must allow the scope for that to happen in ways that reflect local priorities and relationships.

That said, even the strongest mutually agreed accountabilities across systems can be stretched to breaking point when contentious decisions must be taken. For the most part, provider collaboratives can be relied upon by the system to find the best pathways using effective clinical leadership, without involvement from the ICB, and should be enabled to do this. However, where provider collaborative members could be in direct competition, for example, in capital funding allocations, there is the need for an honest broker to mediate these discussions; a role that sits comfortably with the ICB. The ICB should be equipped to interact with the NHSEI leadership to minimise undue interference, and to provide a best interest view in line with the expectations of the ICS.

But what if the relationships are truly frayed? What if the provider collaborative and ICB don’t see themselves as allies in a system, but combatants in highly pressurized and poorly resourced environment? The NHS Confederation hopes that as we shape and adjust our offer through our Provider Collaborative Forum, we will support our members to address or avoid these challenges.

Understanding the appropriate level for delivery of care will protect against horizontal provider collaborative monopolies

A great deal of the discussion about provider collaboratives to this point, particularly in large ICSs, has focused on horizontal collaboration across providers of the same type working within or beyond an ICS footprint. These collaborations work well at system level when the focus is on delivering the most effective use of resources, such as specialist skills, capital and workforce, and creating a culture of change to support innovation. The lesser discussed vertical collaboratives should be utilised to build clinical pathways based on patient need, with greater potential for leftward shift of services in to primary, community and preventative care, particularly at place.  

Though it is likely that certain types of work will be aligned to certain types of provider collaboratives, it’s important that this is not assumed and that systems do not just default to using provider collaboratives when other delivery options may be a better fit. Taking acute providers as an example, they will inevitably be working together on addressing system issues such as elective backlog and specialist service reconfiguration. But, they will still be delivering frontline services to residents of local areas and will need to invest energy in collaborating with other parts of the sector – including primary care and voluntary sector partners - to maximise the wellbeing of those residents and tackle health inequality.

Quite simply, the ICB and provider collaboratives in the ICS need to know what contribution they are making toward achieving their overarching strategy

Careful consideration by the ICS of the level at which it is best to intervene should result in effective allocation of resource to both types of collaboratives, and to those providers who may fall outside of formal collaborative arrangements.  

Quite simply, the ICB and provider collaboratives in the ICS need to know what contribution they are making toward achieving their overarching strategy. They are the parts that make up the whole system and their integrated working approach directly equates to success in achieving their mission. And the beauty of the legislation is, they get to decide what this approach looks like and aims to deliver. Some of the culture of competition and the historic provider/commissioner split may be difficult to shake, but with every structure putting the system at the centre of their decision-making, from providers to NHSEI, greater integration should start to deliver better health outcomes.

As Professor Sir Chris Ham says: “Only in this way will ICSs be able to rely on mutual trust and reciprocity rather than old style oversight and regulation.”

Matthew Taylor is chief executive of the NHS Confederation. Helen Hunter is assistant director (North West) at the NHS Confederation.

Follow both Matthew and Helen on Twitter @FRSAMatthew and @helenwhwc