Integrated care partnerships: driving the future vision for health and care

Foreword

Now that most integrated care partnerships (ICPs) have been up and running for well over a year, it is a good time to take stock of their priorities for improving population health outcomes and their ambitions for the future. The NHS Confederation’s ICS Network and Local Government Association (LGA) have drawn on conversations with senior ICP leaders across England to identify common themes and key characteristics of what leaders would define as effective
ICPs. We hope that it will be useful to all ICP leaders and their partners in helping them to consider their own culture, ways of working and priorities for improving health outcomes. Most of all we hope that this document helps ICP leaders and all other stakeholders identify and appreciate the unique contribution they can make.

We hope this document helps ICP leaders appreciate the unique contribution they can make

What comes across from these conversations is the huge diversity in the way ICPs are structured, their priorities, their ambitions for the future and the purpose attributed to them. But this diversity doesn’t mean that there are not common themes emerging, or that we cannot learn from each other. As membership bodies representing NHS organisations and local authorities, the ICS Network and the LGA are committed to showcasing good practice and supporting our members to reach their full potential. This report highlights some of the many innovative ideas that ICPs have developed in order to spread good practice. We have also identified the key learning so far on the essential characteristics of effective ICPs.

While this report is primarily intended to enable ICPs, their leaders and partners to learn from one another, the research also informed a handful of recommendations for national government. We are clear that for ICSs to succeed, national government stakeholders should give equal credence to ICP leaders in their work, not just focusing on ICBs; they should minimise any efforts to introduce or revamp existing guidance or requirements around the development of strategies so that we can focus on delivering for our populations, not just planning; and they should pursue ever closer, more joined-up working between government departments and other branches of government to mirror the integration that is already taking place at local level.

ICSs are united by the financial and demand pressures facing all parts of the NHS, local government and our stakeholders. We know this winter is going to be one of the toughest we have ever faced – for our health and care systems and our communities. In such trying circumstances it is understandable that the immediate concerns dominate. But it is the vital job of the ICP to keep a focus on effecting long-term transformation: a change in culture and the
way we work together and with our communities; a change in the care and support we provide to maximise health and independence and minimise the need for in-patient care; and a change in health outcomes for our communities. 

ICPs have made a good start in trying circumstances and this report shines a light on the path ahead.

Cllr Tim Swift
Chair, West Yorkshire Health and Care Partnership Board

Cllr Tim Oliver
Chair, Surrey Heartlands ICP

Cllr David Fothergill
Chair, LGA Community Wellbeing Board

Dame Gill Morgan
Chair, ICS Network

Introduction

Integrated care systems (ICSs) became formal partnerships under the Health and Care Act 2022. Defined by their two central governance structures – the integrated care partnership (ICP)
and the integrated care board (ICB) – systems were assigned four common goals:

1. Improving outcomes in population health and health care.
2. Tackling inequalities in outcomes, experience and access.
3. Enhancing productivity and value for money.
4. Helping the NHS to support broader social and economic
   development.

ICPs bring together an alliance of partners concerned with improving care, health and wellbeing

The legislation established ICPs, committees jointly formed between the ICB and all upper-tier local authorities within the ICS area. ICPs bring together an alliance of partners concerned with
improving the care, health and wellbeing of its population, with membership determined locally. The sole statutory duty of the ICP is to produce an integrated care strategy setting out how the
ICB and the local authorities concerned will meet the health and wellbeing needs of its population.

Beyond this, local partners have the freedom to determine the membership, structure and purpose of ICPs. ICPs are being thought about differently up and down the country, and vary
heavily based on local arrangements with place partnerships, health and wellbeing boards and broader system structure. Patricia Hewitt’s recent review of integrated care systems recognised the leadership of ICPs in accelerating the scale and pace of change towards prevention, a focus on wider determinants of health, and real impact on health inequalities and social and economic
development.

The NHS Confederation’s ICS Network and Local Government Association have together established the national forum for ICP chairs, which is valued as a place for ICP chairs to discuss common challenges and share good practice. We are working with the Department of Health and Social Care to enable it to become a crucial vehicle for two-way communication between ICP chairs and national government and its agencies about what is needed to make ICSs a success.

This publication is based on data collected through desk research and semi-structured interviews with 20 leaders from across ICSs, including ICP chairs, ICB chairs and chief executives, directors of strategy and partnerships, directors of public health and other
local government officers from across the country. We conducted analysis of the results of the interviews and ran two roundtables with voluntary, community and social enterprise (VCSE) partners and organisations that represent patients and the public to hear their views on the role and future of ICPs.

Essential characteristics of effective ICPs

ICP leaders identified seven essential characteristics that underpin effective ICPs.

1. Build partnerships of equals

Effective partnerships must be equal. That means no single member of the partnership feels overshadowed, undervalued or outnumbered, and no partner becomes the de facto lead.
Interviewees recognised that this goes beyond just how ICP meetings operate, but also how their activities are resourced, organised and presented. Furthermore, there must be an equality
of partnership between the ICP and the ICB to ensure that the longer-term preventative approach set out in the integrated care strategy is given equal prominence with the joint forward plan of the ICB, which is more likely to focus on delivery of health services.

Crucially, many ICPs are chaired or co-chaired by councillors to ensure local government is given a significant role in their leadership. In some systems, they are chaired or co-chaired by
directors of public health and mayors, such as Paul Dennett in Greater Manchester and Oliver Coppard in South Yorkshire. A small number of systems have appointed independent chairs. Moreover, some ICPs have dedicated directors and teams funded by either the NHS, local authorities or both, with reporting lines into ICP leadership. This allows for a degree of independence from the ICB while also recognising the value in close alignment between ICBs,
ICPs and local authorities.

“Our partners from the VCSE sector say that, at the ICP, they feel like genuine, equal partners. This has come about through relationship building, listening to VCSE leaders about their priorities, and creating agendas which give a voice to VCSE leaders and providers. This is crucial to our development and ways of working.” Sarah Perman, Interim Director of Public Health, Hertfordshire County Council

2. Enable and empower local decision-making

Leaders recognised most integration and change will happen locally, and they emphasised the need for continual assessment of how the ICP’s priorities and actions enable rather than stifle what leaders are doing locally.

“All four place leads are crucial contributors to our integrated care partnership, but in Surrey we are giving real focus to the 27 ‘towns’ because this is the way people in Surrey understand ‘place’, not just regarding the provision of care but also socially and economically. Our ICP will visit all 27 towns and look at how we can together drive progress, tackle inequality, and overcome barriers.” Cllr Tim Oliver, Chair, Surrey Heartlands ICP

3. Embed accountability

Leaders emphasised that it is vital for all partners to hold each other equally accountable for driving forward their collective strategies, rather than for one body within the system to hold the
other partners to account. This is crucial to building partnerships of equals. As explored in the section on purpose, the role of the ICP as a ‘critical friend’ to all component organisations in the system was a common theme – the constructive challenger that can help to identify and unblock issues.

4. Promote a trusting and transparent culture

Many leaders emphasised the role of the ICP in promoting a shared culture based on trust, mutual respect and transparency within a system, through inspiring leadership and professional humility, which recognises and values all partners’ contributions. Leaders cited development days and time spent on personal relationships as crucial to this and it is seen as paying dividends during times of challenge (for example, running cost allowance reductions, local elections and winter pressures). Several leaders stated that the aim was not to avoid disagreements or tensions between ICP partners but to develop a robust and sustainable shared culture in which to manage and overcome tensions.

5. Enable wider participation

Interviewees highlighted the role of ICPs in enabling participation from the voluntary, community, and social enterprise (VCSE) sector, the public and patients as well as partners such as academia, local business and emergency services. Moreover, doing this in a meaningful way so decisions and services were truly coproduced. They emphasised the qualitative difference between communication between ICBs and ICPs and their partners, including the public, and co-production. Clear communication is important to ensure that everyone knows the ICP priorities and what action will be taken to achieve them. But co-production – which involves all partners and the wider community in identifying challenges, developing priorities and delivering progress – must underly the ICP.

6. Have the right governance for their ICP

Many leaders highlighted the importance of putting in the hard yards to agree a governance structure that is right for each system, rather than implementing a model that simply does not work locally or taking for granted what others have said is the right approach. Putting effort into designing governance structures that suit the specific circumstances of each system will pay off in the long run. This helps to reduce bureaucracy where it is not needed and save valuable time for leaders and partners who often have responsibilities far beyond those relating to ICPs.

7. Build in a focus on the long-term vision

Interviewees were keen to highlight that the ICP provides a unique opportunity to look beyond the immediate and urgent priorities facing ICSs and their component organisations and consider
how to achieve their long-term vision of improved population health outcomes, reduced health inequalities and greater focus on prevention and wellbeing. They all recognised that it will take
time to see tangible progress on the changes they are all pursuing. The ability of the ICP to maintain a steadfast eye on the long-term trajectory of the system gives the ICP unique purpose, while ICBs and partner organisations individually can give greater attention to important short-term priorities.

Purposes of ICPs

ICPs have one important statutory responsibility – to develop, publish and keep under review their integrated care strategy. However, many are looking beyond this to develop a wider purpose. Throughout our interviews leaders identified three key purposes for their ICP. Some ICPs had more than one purpose, but the emphasis was almost always placed on one of three ‘C’s: as a convenor, as a vehicle for change, or as a challenger to the status quo.

The convenor partnership

In a convenor partnership, the primary purpose of the ICP is to bring a broad coalition of partners together to set and pursue shared objectives and take collective action.

In these partnerships:

• There is often a ‘core committee’ which drives action, and an ‘assembly’ aimed at establishing a broad coalition of partners.
• There is a focus on consensus-finding, identification and pursuit of shared priorities and agreeing how to use all the tools at partners’ disposal to have maximum impact for their
  communities.
• The work is strategic, driving delivery among its partners.
• It can act as a ‘mediator’ to help find solutions. It acts, in the words of one interviewee, as a “non-political wrap of film around the system”.

The change partnership

In a change partnership, the primary purpose of the ICP is to bring together partners to identify cross-system priorities, to immerse itself in their detail and to drive transformative change to provide maximum impact for the population it serves.

“The ICP is crucial for making non-health service change happen. For example, looking at the first 1,001 days of a child’s life, and specifically something like breastfeeding rates, the ICB has a responsibility to encourage breastfeeding but we also require wider societal, cultural change and that is where the ICP can have real impact.” Simon Bryant, Director of Public Health, Hampshire County Council, and Co-Chair, Hampshire and Isle of Wight ICP

In these partnerships:

• The focus is on bringing together the right cast of actors to drive action and improvement.
• This cast of actors may vary depending on the issues being prioritised, though there will be a consistent core group, including the ICB and local authorities no matter what issue is
  being prioritised.
• The partnership’s role is to draw on the broadest range of expertise to have maximum impact, often thinking in nontraditional terms – for example a shift away from typical NHS
  levers for change.

The challenge partnership

In challenge ICPs, their purpose is to provide a counterweight – or challenge – to what is often the NHS’s focus on short-term priorities, such as forthcoming winters, elective backlogs, acute
performance and GP waiting times.

In these partnerships:

• Their leaders are explicit about a focus on the wider determinants of health (such as housing, climate change and education).
• Leaders focus on the strategic direction of the system in its broadest sense, and its long-term ambitions, rather than practical delivery in the here and now.
• They can be seen to have an accountability role, using integrated care strategies as the lever to drive change.

The diversity of ICPs demonstrates that they have benefited from the flexibility allowed in the
legislation and guidance

The ICS Network and LGA reiterate leaders’ views that there should not be a limited menu of models or approaches prescribed for ICPs. The sheer diversity of ICPs demonstrates that they
have benefited from the flexibility allowed in the legislation and guidance. In discussions with wider partners, it was suggested that the ambition for ICPs could be to develop in all three roles:
convening, driving change, and providing constructive challenge. If the ICP does not fulfil these functions, it could instead look at where these functions are delivered across the system and assess how this works best locally.

The future of ICPs

We are still early in the journey of integrated care systems across England, and ICPs, having been established after ICBs, are still working through important decisions about how they will operate and function as part of a system. That said, in the ICS Network’s state of ICSs survey of ICS leaders, most respondents (58 per cent) felt their ICPs were sufficiently mature and resourced to deliver the ambitions set out in their integrated care strategies. ICPs have now developed their first integrated care strategies and are putting into action creative and transformative programmes to achieve their ambitions.

We asked ICP leaders what they hoped their ICPs would achieve over the next three to
five years. The responses reflect a mixture of population outcome ambitions and system
processes that leaders want to see progress on and highlights the breadth of their ambitions.

In our conversations with ICP leaders we have identified common themes regarding their ambitions:

• integrated planning
• shared priorities and vision
• prevention
• the wider determinants of health
• social and economic development.

Moreover, it was particularly welcome to see a focus on improvements in support for children and young people, children with special education needs and disabilities (SEND), and mental health services more broadly.

While ICPs are still relatively new, their leaders are starting to put in place meaningful programmes and developments that are helping them to achieve these goals. We have included these as ‘spotlights on good practice’ throughout the report.

Recommendations

Though this paper is primarily about sharing best practice with regard to ICPs, through this process three asks were clear for national government:

1. The Department for Health and Social Care (DHSC) and NHS England should give equal priority to ICPs and ICP leadership alongside ICB leadership in their work, for example, including them in ICS performance meetings.
2. DHSC and NHS England should only make changes to strategy development guidance when systems request it, to shift behaviours away from continual strategy development and towards impact for patients and the public.
3. Parallel integration should take place across Whitehall to deliver a true health in all policies approach and to provide more consistency in what is asked of system partners. ICPs
   should also be considered as crucial partners for national government in health and care policy development as purveyors of the breadth of public services that impact on
   people’s health outcomes.

Next steps

The ICS Network and LGA will continue to support the development of ICPs through our jointly run ICP Chairs Forum, bespoke development support, and further work on key issues identified through this process. We are also establishing a mechanism for ICP Chairs to formally engage with a cross-government cohort of stakeholders to inform policymaking.

Further reading

This publication is purposefully succinct and focused on how ICPs have developed to date and what their leaders have planned. The ICS Network, LGA and wider partners have developed a host of resources in recent years to support ICPs and their partners as they develop.

Consider reading:

• Systems for change: Driving social and economic development in integrated care systems
• The state of integrated care systems 2022/23: Riding the storm
• The Hewitt Review: an independent review of integrated care systems
• NHS Confederation: The rising cost of living
• Prioritising prevention policy in integrated care systems
• Developing a systems narrative to prevention – MEPS framework
• Major Conditions Strategy – tackling multimorbidity
• Delivering Meaningful Patient Involvement: The MTG’s Guide for Integrated Care Systems | The Medical Technology Group
• Untapped Potential: Bringing the voluntary sector’s strengths to health and care transformation | Richmond Group of Charities

About us

The NHS Confederation is the membership organisation that brings together, supports and speaks for the whole healthcare system in England, Wales and Northern Ireland. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care and reducing health inequalities.

The Integrated Care Systems Network is part of the NHS Confederation. As the only national network bringing together the leaders of health and care systems, it supports ICS leaders to
exchange ideas, share experiences and challenges, and influence the national agenda.

For more information visit www.nhsconfed.org/ics

The Local Government Association (LGA) is the national voice of local government. We are a politically led, cross-party membership organisation, representing councils from England and Wales. The membership comprises 315 of the 317 councils in England, and includes district, county, metropolitan and unitary authorities, along with London boroughs and the City of London Corporation.

The LGA’s role is to support, promote and improve local government, and raise national awareness of the work of councils. They provide the bridge between central and local government and aim to influence the political agenda on issues that matter in order to help councils deliver the best services to local communities.

For more information visit www.local.gov.uk/