ICS Design Framework

Key points

• The ICS Design Framework sets out NHS England and NHS Improvement's (NHSEI) expectations for the next stage of system development.
• The framework outlines the core features of integrated care systems (ICS) and the expectations/minimum standards NHSEI has in terms of membership of ICS bodies, their roles and accountabilities, governance and management arrangements, financial allocations, models for clinical and professional leadership, working with people and communities and managing data. It provides indicative outputs expected in every ICS over the course of the transition period in 2021/22.
• The framework sets out the core features of every ICS, while emphasising the need for local flexibility and determination.
• Some aspects of system development – including all content referring to new statutory arrangements and duties, and/or which is dependent on the implementation of such arrangements and duties – will depend on changes to the government’s legislation on integration and its parliamentary process.
• In due course, NHSEI will provide further guidance on the membership and governance of ICS NHS bodies; the composition and operation of the board; how to support ICS NHS bodies to manage conflicting roles and interests of board members; provider collaboratives; provider governance; and supporting people transition planning and implementation.

In summary

The framework is based on the objectives set out in Integrating Care: Next Steps, as reflected in the government’s white paper. However, all content referring to statutory accountabilities will depend on the final contents of the bill when it passes into law. NHSEI is therefore clear that systems should not yet implement arrangements or make decisions that require the authority of a change in the law.

Local flexibility

The framework states that each ICS should continue to determine how and where specific activities are best carried out to reflect local circumstances and relationships, ensuring all ICS activities are publicly transparent and accountable, professionally and clinically led, and directly involve local communities and people who use services. ICS leadership and governance arrangements have been designed locally to best reflect local circumstances. NHSEI want this to continue, and to see ICSs agree their next stage of development with local government, the NHS, other partners such as the voluntary, community and social enterprise (VCSE) sector, and residents.

The ICS partnership

Each ICS partnership will be responsible for agreeing an integrated care strategy for improving health care, social care and public health across their whole population, using the best insights from data available, built bottom-up up from local assessments of needs and assets identified at place level and focusing on reducing inequalities and addressing the consequences of the pandemic for communities. To support this process, formal guidance on integrated care partnerships will be developed jointly by the Department of Health and Social Care, NHS England and the Local Government Association, and consulted on ahead of implementation, including on the role and accountabilities of the chair of the integrated care partnership.

The ICS partnership is expected to be established locally and jointly by the relevant local authorities and the ICS NHS body, evolving from existing arrangements and with mutual agreement on its terms of reference, membership, ways of operating and administration.

Local authorities that provide social care services in the ICS area and NHS organisations must be included. Beyond this, members may be from health and wellbeing boards, other statutory organisations, VCSE sector partners, social care providers and organisations with a relevant wider interest such as employers, housing and education providers. The membership may change as the priorities of the partnership evolve. (Further detail can be found on pages 8-11, including ten guiding principles for partnerships).

The ICS NHS body

Each ICS NHS body will be responsible for:

• Developing a plan to meet the health needs of the population within their area, having regard to the partnership’s strategy and the local health and wellbeing strategy, ensuring NHS services and performance are restored following the pandemic and that constitutional standards (including statutory duties for quality) and Long Term Plan commitments are met.
• Allocating resources to deliver the plan by deciding how its national allocation will be spent across the system.
• Establishing joint working arrangements with partners that embed collaboration as the basis for delivery of joint priorities. The ICS NHS body may choose to commission jointly with local authorities across the whole system; at place where that is the relevant local authority footprint.
• Establishing governance arrangements to support collective accountability between partner organisations for whole-system delivery and performance, underpinned by the statutory and contractual accountabilities of individual organisations, to ensure the plan is implemented effectively within a ‘system financial envelope’ set by NHSEI.
• Arranging for the provision of health services in line with the allocated resources across the ICS footprint through a range of collaborative leadership activities, including: putting contracts and agreements in place to secure delivery of its plan by providers; convening and supporting providers to lead major service transformation programmes; and putting in place personalised care.
• Leading system implementation of the People Plan by aligning partners across each ICS to develop and support the ‘one workforce’.
• Leading system-wide action on digital and data to drive system working and improved outcomes.
• Use joined-up data and digital capabilities to understand local priorities, track delivery of plans, monitor and address variation and drive continuous improvement in performance and outcomes.
• Working alongside councils to invest in local community organisations and infrastructure and, through joint working between health, social care and other partners including police, education, housing, safeguarding partnerships, employment and welfare services, ensuring that the NHS plays a full part in social and economic development and environmental sustainability.
• Driving joint work on estates, procurement, supply chain and commercial strategies to maximise value for money across the system and support these wider goals of development and sustainability.
• Leading the preparation and execution of emergency response.

Further detail can be found on pages 12-15.

All still relevant clinical commissioning group (CCG) functions and duties will transfer to an ICS NHS body when they are established, along with all CCG assets and liabilities, including their commissioning responsibilities and contracts. NHSEI will clarify in guidance how these statutory duties will transition to ICS NHS bodies.  

The board of the ICS NHS body will be responsible for ensuring that the body meets all its statutory duties.

People and culture

Systems' people plans should be aligned with the partnership’s plan and refreshed annually taking into account national priorities.

From April 2022, ICSs will be expected to shape the approach to growing, developing, retaining and supporting the people employed by the ICS and its constituent organisations in their areas, ensuring the delivery of high-quality services and care for the population. ICS NHS bodies should adopt a ‘one workforce’ approach and develop shared principles and ambitions for people and culture with local authorities, the VCSE sector and other partners.

Specific expectations of systems for workforce are laid out on pages 16-18.

To support ICS NHS bodies to discharge these responsibilities and deliver national and local people and workforce priorities, alongside Health Education England, NHSEI will publish supplementary guidance and implementation support resources for ICSs on developing their strategic people capabilities, including a people operating model.

Governance and management arrangements

The ICS NHS board

The ICS NHS unitary board will be the senior decision-making structure for the ICS NHS body, providing strategic leadership. All members of the board will make decisions as a single group and will have collective and corporate accountability for delivery of the functions and duties of the ICS and the performance of the organisation.

The statutory minimum membership of the board of each ICS NHS body will be confirmed in legislation. In order to carry out its functions effectively, NHSEI expects every ICS NHS body to establish board roles above this minimum level, so in most cases they will include the following roles:

• Independent non-executives: Chair plus a minimum of two other independent non-executive directors (as a minimum required to chair the audit and remuneration committees). These individuals will normally not hold positions or offices in other health and care organisations within the ICS footprint.
• Executive roles (employed by the body): Chief executive (who will be the accountable officer for the funding allocated to the ICS NHS body), director of finance, director of nursing and medical director.
• Partner members: a minimum of three additional board members, including at least:
  • one member drawn from NHS trusts and foundation trusts who provide services within the ICS’s area
  • one member drawn from the primary medical services (general practice) providers within the area of the ICS NHS body
  • one member drawn from the local authority, or authorities, with statutory social care responsibility whose area falls wholly or partly within the area of the ICS NHS body.

The detailed membership of each board (along with the ICS body’s decision-making and other governance arrangements) should be set out in a constitution, which will be subject to NHSE approval. Beyond these positions, the ICS NHS body’s constitution may provide for specific executive or non-executive members to ensure that the board is well governed and can meet its statutory duties and objectives. NHSEI will issue guidance to support this (further detail on page 19-22, including expectations of the board).

NHSEI expects all members of the board will be required to comply with the Nolan Principles of Public Life, and meet the fit and proper persons test, and boards must have clear governance and board-level accountability for discharging the associated regulations.

It will be important that boards have strong leadership on issues that impact upon organisations and staff across the ICS, including the people agenda and digital transformation. NHSEI will publish further guidance on the management of conflicting roles and interests and supporting guidance for systems to use in developing their local arrangements, including an ICS NHS body model constitution. Our ICS Network is feeding into the development of this.

Committees and decision-making

The ICS NHS body, as the ICS more broadly, must ensure they have appropriate clinical representation in their decision-making arrangements as part of their wider commitment to clinical and professional leadership (more detail in the ‘Clinical and professional leadership’ section below).

All ICS NHS bodies will be required to have an audit committee and a remuneration committee. The board may decide to establish further decision-making committees, in accordance with its scheme of delegation. The board may also establish advisory committees to advise it on discharging certain duties, such as public and patient engagement.

Given that ICSs will have significant flexibility in how and where decisions and functions are undertaken, NHSEI requires every ICS NHS body to maintain with ICS partners a ‘functions and decision map’ showing their arrangements, including any new commissioning functions delegated or transferred by NHSE.

The ICS NHS body will have the power to appoint individuals who are not board members or staff of the ICS NHS body to be members of any committee it has established and the ICS NHS body and NHS trusts/FTs will have the power to establish together joint committees to which they may delegate responsibilities in accordance with those bodies’ schemes of delegation.

The body’s constitution should lay out any committees’ governance arrangements, which should include appropriate reporting arrangements.

Place-based partnerships

The framework states that all systems should establish and support place-based partnerships, with configuration and catchment areas reflecting meaningful communities and geographies that local people recognise. 

The ICS NHS body will remain accountable and therefore the governance and leadership arrangements put in place should support safe and effective delivery of the body’s functions and responsibilities alongside wider functions of the partnership.

Local partners will agree the form of governance that place-based partnerships adopt, having regard to existing local configurations and arrangements. Depending on the context and functions to be carried out at place level, governance arrangements may include the following, possibly in combination: consultative forum; (joint) committee of the NHS ICS body; individual directors of the NHS ICS body; lead provider (further detail on pages 23-25).

The roles of place-based leaders will include convening the place-based partnership, representing the partnership in the wider structures and governance of the ICS and (potentially) taking on executive responsibility for functions delegated by the ICS NHS body chief executive or relevant local authority.

Supra-ICS arrangements

The governance mechanisms to support supra-ICS arrangements will need to be co-designed between the relevant providers, NHS ICS bodies clinical networks or alliances and, where relevant, NHSEI’s regional teams. ICSs and ambulance providers should agree their working relationships carefully to ensure that, where appropriate, there is a joined-up dialogue between ICSs and their relevant ambulance provider, avoiding unnecessary variation in practice or duplication of communication.

Quality governance

ICS NHS bodies will need to resource quality governance arrangements appropriately, including leading system quality groups (previously quality surveillance groups) and ensuring that clinical and care professional leads have capacity to participate in quality oversight and improvement. Operational support will also be provided through NHSEI regional and national teams in line with National Quality Board’s guidance, namely the refreshed Shared Commitment to Quality and the Position Statement. These key documents set out the core principles and consistent operational requirements for quality oversight that ICSs are expected to embed during the transition period (2021/22) and beyond.

The role of providers

The framework positions organisations providing health and care services as the frontline of each ICS. The contracts health service providers hold (NHS Standard, or national primary care supplemented locally ¹ ) are expected to evolve to support longer term, outcomes-based agreements, with less transactional monitoring and greater dialogue on how shared objectives are achieved.

Primary care in integrated care systems

The framework emphasises the role of primary care in decision-making at all levels of the ICS, including strategic decision-making forums at place and system level. In particular, ICSs should ensure primary care professionals are involved in the development of shared plans at place and system, ensuring they represent the needs of their local populations at the neighbourhood level of the ICS, including with regards to health inequalities and inequality in access to services.

ICSs and place-based partnerships should also consider the support that PCN clinical directors, as well as the wider primary care profession, may need to develop primary care and play their role in transforming community-based services. Place-based partnerships may also wish to consider how to leverage targeted operational support to their PCNs, for example with regard to data and analytics for population health management approaches, HR support or project management.

Voluntary, community and social enterprise partners

The framework stipulates that VCSE partnership should be involved in governance structures and system workforce, population health management and service redesign work, leadership and organisational development plans.

By April 2022, ICSs and the ICS NHS body will develop a formal agreement for engaging and embedding the VCSE sector in system level governance and decision-making arrangements, ideally by working through a VCSE alliance to reflect the diversity of the sector. A national development programme is in place to facilitate this in all areas.

The framework provides further details on the envisaged role of independent sector providers as well as NHS trusts and foundation trusts on pages 29-30.

The new provider selection regime

NHSEI has recommended that parliament legislates to remove the current rules governing NHS procurement of healthcare services; and that these are replaced by a new regime specifically created for the NHS. NHSEI recently consulted on the new Provider Selection Regime, which would give decision-makers greater discretion in how they decide to arrange services, with competition and tendering a tool to use where appropriate, rather than the default expectation. The regime would need to be applied by NHS bodies (NHSE, ICS NHS bodies, NHS trusts and FTs) and local authorities when making decisions about who provides healthcare services. The regime sets out some key criteria decision-makers need to consider when arranging services, as well as requirements around transparency and scrutiny of decisions. Further details on pages 30-31.

Provider collaboratives

From April 2022, trusts providing acute and/or mental health services will be expected to be part of one or more provider collaboratives. Community trusts, ambulance trusts and non-NHS providers (such as community interest companies) should participate in provider collaboratives where this is most beneficial for patients and makes sense for the providers and systems involved. ²  

Provider collaboratives will agree specific objectives with one or more ICS, to contribute to the delivery of that system’s strategic priorities. The members of the collaborative will agree together how this contribution will be achieved.

It will be up to providers, working with partners, to decide on the specific model and best governance arrangements for their collaboratives.

The ICS NHS body and provider collaboratives should define their working relationship, including participation in committees via partner members and any supporting local arrangements, to facilitate the contribution of the provider collaborative to agreed ICS objectives. 
NHSEI will publish further guidance on provider collaboratives in due course. Further details on pages 31-32.
 

Clinical and professional leadership

All ICSs should develop a model of distributed clinical and care professional leadership, and a culture which actively encourages and supports such leadership to thrive. This includes ensuring professional and clinical leaders have protected time and resource to carry out system roles, and are fully involved as key decision-makers, with a central role in setting and implementing ICS strategy. 

Specific models for clinical and care professional leadership will be for ICSs to determine locally and we recognise that ICSs are at different stages of development in this regard. NHSEI will provide guidance describing the features of an effective model, informed by more than 2,000 clinical and care professionals and illustrating case studies from systems with more advanced approaches. The five features are outlined in full on page 33.

ICSs are expected to use the resources to support self-assessment of their clinical and professional leadership model and implement mechanisms to measure their progress and performance. Systems are also encouraged to consider how they could adopt a peer review approach to development in this area, buddying with other systems to undertake their assessment and develop subsequent plans.

For the NHS ICS body, the clinical roles on the board, described in the governance and management arrangements section, are a minimum expectation, ensuring executive-level professional leadership of the organisation. Individuals in these roles are expected to ensure leaders from all clinical and care professions are involved and invested in the purpose and work of the ICS.

The ICS NHS board will be expected to sign off a model and improvement plan for clinical and care professional leadership that demonstrates how clinical and care professions are invested in the purpose and work of the ICS. This will also help to ensure that the five features referenced above are reflected in governance and leadership arrangements.

Working with people and communities

ICSs will need to build a range of engagement approaches into their activities at every level and to prioritise engaging with groups affected by inequalities. It is expected this will be supported by a legal duty for ICS NHS bodies to make arrangements to involve patients, unpaid carers and the public in planning and commissioning arrangements, and by the continuation of the existing NHS trust and FT duties in relation to patient and public involvement, including the role of FT governors.

Working with a range of partners such as Healthwatch, the VCSE sector and experts by experience, the ICS NHS body should assess and where necessary strengthen public, patients’ and carers’ voice at place and system levels. Arrangements in a system or place should not just provide commentary on services, but should be a source of genuine co-production and a key tool for supporting accountability and transparency of the system.

NHSEI has set out seven principles for how ICSs should work with people and communities on page 36. ICSs should use these principles as the basis for developing a system-wide strategy for engaging with people and communities (further details on page 36).

Each ICS NHS body should use these principles as a basis for developing a system-wide strategy for engaging with people and communities. As part of this, the body should work with its partners across the ICS to develop arrangements for:

• Ensuring the ICS partnership, and place-based partnerships have representation from local people and communities in priority setting and decision-making forums; and
• Gathering intelligence about the experience and aspirations of people who use care and support, using these insights to inform decision-making and quality governance.

More detailed information on this will be made available to systems in forthcoming guidance on membership and governance of ICS NHS bodies and in the implementation support for how ICSs work with people and communities.

Accountability and oversight

The members of the NHS body unitary board will have collective and corporate accountability for the performance of this organisation and will be responsible for ensuring its functions are discharged. NHSE, through its regional teams, will agree the constitutions and plans of ICS NHS bodies and hold them to account for delivery through the chair and chief executive.

Building on the relationships and ways of working they have developed to date, system partners (including local government) will need to maintain a working principle of mutually accountability, where, irrespective of their formal accountability relationships, all partners consider themselves collectively accountable to the communities they serve, and to each other for their contribution to the ICS’s objectives.  

Providers of NHS services will continue to be accountable:

• for quality, safety, use of resources and compliance with standards through the provider licence (or equivalent conditions in the case of NHS trusts) and CQC registration requirements
• for delivery of any services or functions commissioned from or delegated to them, including by an NHS ICS body, under the terms of an agreed contract and/or scheme of delegation.

Executives of provider organisations will remain accountable to their boards. Where an executive of an NHS provider organisation sits on the board of an NHS ICS body, they will also be accountable – with other board members – for the performance of the ICS body and ensuring its functions are discharged. When acting as an ICS body board member, they must act in the interests of the ICS body and the wider system, not those of their employing provider. 

NHSEI will provide guidance to support ICS NHS bodies to manage conflicting roles and interests of board members.

Approach to NHS oversight within ICSs

The oversight arrangements for 2022/23 will build on the final 2021/22 System Oversight Framework (SOF). NHSEI expects these arrangements to confirm ICSs’ formal role in oversight including:

• bringing system partners together to identify risks, issues and support needs and facilitate collective action to tackle performance challenges
• leading oversight and support of individual organisations and partnership arrangements within their system.

While ICS NHS bodies will, by default, lead local oversight and assurance, NHSE’s statutory regulatory responsibilities will be similar to the existing ones of NHS England and Improvement. This means that any formal regulatory action with providers will, when required, be taken by NHSE.

NHSE will work with each ICS NHS body to ensure effective and proportionate oversight of organisations within the ICS area, with arrangements that reflect local delivery and governance arrangements and avoid duplication.

Systems will also benefit from existing local authority health overview and scrutiny committees reviewing and scrutinising their work. 

Accountability and transparency in ICSs will also be supported via:

• clearly agreed and articulated arrangements for how the system works with people and communities; and
• public meetings, published minutes and regular and accessible updates on the ICSs’ vision, plans and progress against priorities.

NHSEI is working with colleagues from CQC and DHSC to agree the process and roles for reviewing and assessing systems. The proposed principles for NHS system oversight are:

• working with and through ICSs, wherever possible, to provide support and tackle problems
• a greater emphasis on local priorities and on system performance and quality of care outcomes alongside the contributions of individual organisations to system goals
• matching accountability for results with improvement support, as appropriate
• greater autonomy for ICSs and organisations with evidence of collective working and a track record of successful delivery of NHS priorities, including tackling inequality, health outcomes and access; and
• compassionate leadership behaviours, that underpin all oversight interactions.

Financial allocations and funding flows

ICS allocations

NHSE will make financial allocations to each ICS NHS body for the performance of its functions. Decisions about spending will be devolved to ICS NHS bodies. This will include the budgets for:

• acute, community and mental health services (currently CCG commissioned)
• primary medical care (general practice) services (currently delegated to CCGs)
• running cost allowance for the ICS NHS body.

This may also include the allocations for a range of functions currently held by NHSE, including other primary care budgets and appropriate specialised commissioning. Further details are given on pages 40-41.

Increasingly, funding will be linked to population need. Allocations will be based on longstanding principles of supporting equal opportunity of access for equal needs and contributing to the reduction of health inequalities.

NHSEI will allocate funding at system level, taking into account population needs and a system’s ‘pace-of-change’.

An open book relationship between providers of NHS services, supported by improved cost data (PLICS), will give further transparency for stakeholders that the NHS is meeting its commitment to deploy resource according to need and tackle inequalities.

Distribution of funds by the ICS NHS body

The spending of the ICS NHS body’s budgets will be part of a plan to deliver financial balance within its system financial envelope, which would also be set by NHSEI. This envelope covers the expenditure of the whole system, including spending made by NHS trusts/FTs for services delivered for commissioners from outside the system.

Financial rules will apply to ensure that key national commitments are delivered, such as the Mental Health Investment Standard and the primary medical and community health services funding guarantee. 

Based on these local priorities and national rules (including the National Tariff Payment System), the ICS NHS body will agree various arrangements (detailed on pages 41-42).

The ICS NHS board and chief executive (AO) will remain responsible for services arranged under delegation arrangements with place-based partnerships or through lead provider contracts and would be required to put in place necessary governance to provide assurance on the spending of public money (further detail on setting budgets for places on pages 43-44).

Financial and regulatory mechanisms to support collaboration

ICS NHS bodies will have a duty to cooperate with other NHS bodies, including NHS trusts and FTs, and local authorities. They also have a duty to promote integration. These duties, combined with the new triple aim duty, should be a key driver for ensuring NHS ICS partners work together to meet the four purposes of the ICS with the resources available.

NHSEI sets out various policy developments and other enablers to support system collaboration on pages 44-45.

The legislation will enable the direct commissioning functions of NHSE to be jointly commissioned, delegated or transferred at an appropriate time to ICS NHS bodies. NHSEI is considering how it might shift some of its direct commissioning functions to ICS NHS bodies. Subject to discussions with systems and NHSEI regions and further work on HR, their intention is to enable ICS NHS bodies to take on responsibility as soon as they are ready to do so after the enactment of legislation.

Commissioning of primary medical services is currently delegated to CGGs and will transition immediately into ICS NHS bodies when they are established. ICS NHS bodies might also take on primary dental services, general ophthalmic and pharmaceutical services commissioning.

NHSE has a range of other direct commissioning functions including health and justice, armed forces and aspects of public health, and engagement with ICSs will continue to establish how they could take on greater responsibility for these services in future.

Data and digital standards and requirements

From April 2022, systems will need to have smart digital and data foundations in place. The way that these capabilities are developed and delivered will vary from system to system. Systems will locally determine the right way to develop these capabilities and to ensure they are available at system and place level, and across provider collaboratives.

The ICS standards and requirements for digital and data will be centred around the What Good Looks Like framework, which identifies seven success measures for digital and data transformation. The framework will be published in the first quarter of 2021/22.

Specific expectations of systems for data and digital, including the implementation of a shared care record, are outlined on pages 47-48.

Managing the transition to statutory ICSs

During the transition period the Employment Commitment asks affected organisations not to carry out significant internal organisational change and not to displace people. This does not apply to those people in senior/board level roles who are likely to be affected by the new ICS board structure and will have to go through organisational change as part of the abolition and establishment process.

The core principles of the Employment Commitment are set out on page 50.

Accountability for managing the change process will be with the current ICS and CCG leadership, with increasing involvement of the new leaders (such as the chair, chief executive and others at board level) who may be appointed on a shadow or designate basis, pending the legislation.

Each ICS should make initial arrangements to manage the transition and ensure that there is capacity in place ready for implementation of the new ICS body. Plans should be agreed with regional NHSEI teams.

It is noted that while plans can be made, systems should not take decisions or enter into arrangements which presume any legislation is already in place or that it is inevitable it will become law, before the parliamentary process has been completed.

The indicative outputs expected in every ICS over the course of the transition period in 2021/22 are set out on pages 51-52.

At some point after the legislation is introduced, NHSE will also publish further resources and guidance to support people transition planning and implementation:

NHS Confederation viewpoint

We welcome the publication of the ICS Design Framework as an important next step in the development of systems. It offers some clarity on the overarching framework for ICSs and explores how the expected legislation should be put into practice, including in key areas such as place-level working, workforce transition and finances. Crucially, however, it retains a high degree of permissiveness so that ICSs can in many areas structure arrangements according to their own local circumstances; something we have consistently pressed for.

We are reassured that key issues we have relayed to NHS England and NHS Improvement have been addressed

We were pleased to have had the opportunity to input into the framework and we are reassured that key issues we have relayed to NHS England and NHS Improvement have been addressed. On the issue of professional and clinical leadership, for instance, the framework states that this ‘should reflect the learning and experience gained from CCG clinical leadership, building out from this to reflect the rich diversity of clinical and care professions across the wider ICS partnership.’ Similarly, it outlines further the crucial role of primary care in system working, acknowledges the importance of the VCSE sector in provider collaboration and reinforces the continuation of national spending commitments such as the Mental Health Investment Standard.

We will work closely with the LGA, DHSC and NHSE to support the development of guidance that offers members clarity of accountability and functions

We do, however, have concerns in some areas. The framework continues to describe a partnership and an NHS body as the two statutory component parts of integrated care systems. However, it also sets out an expectation that the partnership will operate as a forum, being established as a committee rather than a corporate body. Given that this part of the ICS is fundamentally about the wider integration of health and care, there is a risk that the partnership board is seen as having a far more diluted role. We will work closely with the LGA, DHSC and NHSE to support the development of guidance that offers members clarity of accountability and functions for this vitally important part of the integrated system governance. 

Another concern is that given the challenges around achieving elective recovery and the increasing demands on mental health and other services, systems may have to look at innovative approaches to when and where services are offered to maximise value and quality of care for patients. If (as expected) the forthcoming legislation introduces increased powers for the Secretary of State to intervene in local service reconfigurations, there may be a reticence from systems and provider collaboratives to fully embrace such opportunities if the defining decisions are then taken centrally rather than by the local system. This issue is largely absent from the framework but is one that we will continue to press the government for further clarification. 

Current leaders must be supported to continue the work required to establish statutory organisations that are fit for purpose by April 2022

Looking ahead, we acknowledge the ongoing uncertainty for all board-level staff, including CCG, ICS leaders and chairs. While it is vital that the appointments processes for ICS chairs, chief executives, executive and non-executive positions and chairs are open, fair and transparent, we recognise this will take time. However, current leaders must be supported to continue the work required to establish statutory organisations that are fit for purpose by April 2022.