Why the success of ICSs may not be measured by their survival

‘ICS are going to be replaced by something else. It’s not a matter of whether, but when.’

This was the view of an NHS leader whose opinions I take very seriously. From recollection, the leader continued along these lines:

‘Things are pretty terrible now and they’re going to get worse before they get better. ICSs won’t be able to change that in the short term, so – however unfairly - they will be blamed. The ambitions to do things different in systems and places, for example, moving resources upstream into community, primary and public health, are commendable, but they will be stymied by integrated care boards (ICBs) spending all their time trying vainly to deliver on the ever-lengthening list of unrealistic expectations poured down on them by DHSC and NHSE.’

Such clear views, so strongly expressed, are impossible to ignore. But what is the right response? Perhaps it has three elements:

1. Being as clear as possible about the value that can and should come from ICSs and the new collaboratives and place-based structures that are emerging alongside them.

Key to this is:

• the transformative potential for integrated care partnerships to redefine health policy around all the major factors that shape health, not just the activities of the health and care system
• the scope to develop and act on system/place-wide solutions to pressing and complex problems such as access, hospital discharge and the care of those with long-term multiple conditions.
• as a corollary of the development of accountability at collaborative level, the opportunity for ICBs to challenge providers to achieve the triple shift of moving to a ‘fully engaged’ health system; from incentivising activity to incentivising outcomes, from meeting demand to addressing need, and moving resources proportionately upstream from acute to community based care, primary and public health.

2. Being a critical friend to the health service’s central hierarchy as it seeks to adapt to leading a system of systems.

Key to this is:

• developing an alternative, more balanced model of change within the health service, which aligns top-down incentives for improvement with lateral, leader-to-leader, system-to-system incentives and also bottom-up drivers, principally the choices and voices of patients and communities
• for the first time in the NHS, fostering a culture of constructive pluralism so that leaders have the collective confidence to engage the centre as equals in designing solutions (and sometimes pushing back against unrealistic expectations).
• developing a framework for innovation which is ambitious in terms of pace and scale but based on a model of the centre enabling and empowering locally-adapted change not (unless where absolutely necessary) imposing centrally mandated templates.

3. Inculcating the perspectives, behaviours and capacities of systems working while acknowledging that these qualities may end up being articulated through different institutional structures

Key to this is:

• honesty and realism about what system working can achieve in the short term in the context of an under-resourced, over-stretched service
• a focus more on the concrete problem-solving practices that system working can enable and less on the institutional context in which those practices emerge
• taking a bottom-up view of strategy development so that, even when national frameworks and priorities change, what is agreed and enacted at a system or place level can be sustained
• appreciating that the disciplines of system working and collaboration are as demanding and concrete as those of market making and competition, and seeking to instil these disciplines in all levels of the health and care system so that they survive any future re-organisation

The Italian communist Antonio Gramsci famously encouraged his fellow revolutionaries to practise ‘pessimism of the intellect, optimism of the will.’ This is memorable but it has never really satisfied me as an injunction. If we have good reason to be fatalistic, it is surely futile to act? As the national organisation, more than any other, invested in making ICSs work I prefer a different maxim from Roberto Unger and Cornell West (I can’t find the precise reference):

 ‘We are led to believe that hope leads to action, in reality it is much more action that leads to hope.’

The reasons to think ICSs will fail are numerous and strong. The reasons to think they might ultimately be seen to have succeeded lie in the commitment, imagination and hard graft which – despite all the pressures – is already clearly visible in many systems.

Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on Twitter @frsamatthew