As the government once again kicks down the road decisions on vital reforms and funding for social care, local areas are establishing the Integrated Care Boards which will lead the new Integrated Care Systems (ICS), bringing together the NHS, local government and partners to plan and deliver integrated services to improve the health of the local population. Building on the progress made since many public health responsibilities transferred back to local government in 2013, this is a great opportunity to address the determinants of health and issues around health inequality. Might ICSs at last lead to an effective local voice in our over-centralised, top-down healthcare system?
Each ICS is supposed to plan at three levels: the neighbourhood (an area of around 40,000 people), the ‘place’ (often a LA area), and the (ICS) system (covering around 2 million people). Working at the neighbourhood level is likely to be somewhat informal, often using a social prescribing approach and developing multi-disciplinary teams including third sector partners. The approach to ‘place’ looks set to vary between areas, with some ICSs devolving significant responsibility (and funding) whilst others centralise these at ‘system’ level. Meanwhile at ‘ICS system’ level, Integrated Care Partnerships (joint LA and health committees) will develop an Integrated Care Strategy to meet the assessed health and social care needs of their population identified in the Joint Strategic Needs Assessments and Wellbeing Strategies prepared by local Health and Wellbeing Boards.
Beyond the formal planning process, the success of local ICSs will partly depend on the quality of local collaborative (managerial and political) leadership – across statutory partners and with the third sector. It will be a tough job to balance the priorities of the national health service and issues of local places, but many local authorities will be able to offer helpful experience , for example from moves to more networked governance approaches.
The National Audit Office recognises the potential but appears dubious on current prospects. Last month it published a review, Introducing Integrated Care Systems: joining up local services to improve health outcomes, finding:
“NHSE has a detailed regime to monitor performance against core NHS objectives but … it is less clear who will monitor the overall performance of local systems, and particularly how well partners are working together and what difference this new model makes…“
The report notes that, whilst government is asking ICSs to set out local priorities and make progress against them, there is no protected funding and few mechanisms to ensure this happens. This leads, as the NAO politely puts it, to “a risk that national priorities, and the rigorous oversight mechanisms in place to ensure they are delivered, crowd out attempts at progress on local issues”. The report also identifies five “high risk” elements of effective integration: clarity of objectives, resourcing, governance and accountability (such as how ICSs will function alongside existing local government Health and Wellbeing Boards and how accountability differences between NHS and local authority bodies will be resolved), and the capacity to balance priorities other than national NHS targets. These urgently need to be addressed if ICSs are to begin to meet their potential.
At one of Inlogov’s “Brown Bag Lunch” discussions earlier this month we agreed on the importance of issues around how ICSs develop, particularly in terms of developing effective system leadership and planning, collaborating with community organisations, and links to wider devolution processes. I’d be interested to hear about experiences in local areas as these develop.
Picture credit: National Audit Office