Comment / Integrated care systems: under starter’s orders

Last Friday, the National Audit Office published Introducing Integrated care systems: joining up local services to improve health outcomes.  To say there were other things going on in the news that day is an understatement. 

The report is unique in that it borrows its approach from the pandemic period, which saw new initiatives examined soon after their launch rather than waiting to see how things turned out.  Although involving another reorganisation within the NHS (and more formal partnering with local government), on this occasion 76% of senior integrated care system (ICS) staff agree the move to ICSs is a good thing.  The same cannot be said of the 2012 reforms.  On a similar note, 77% consider their ICS has an intention to invest in preventative measures to improve outcomes, the crunch coming in that only 31% think there is the capacity to do this.

The NHS long-term plan set out the benefits of placing ICSs on a statutory footing, but their four core purposes provide the lens through which we examined their setup and the risks they need to manage.  In short, they are designed to: improve outcomes; tackle inequalities; enhance productivity; and support broader social and economic development.  A valid question arises. How will you know they are working?

The environment in which they’ve been introduced will be well understood by many and produces few surprises.  Readers will recognise key stats and figures such as a 9.7% vacancy rate, £9bn in backlog maintenance, provider savings plans that range from 1.2% to 10.4% of budgets, a waiting list of between six and seven million, emergency pressures and all of this coming at a time of rising inflation.  For 2022/23, over a third of ICS efficiency plans (£5.7bn in total) are non-recurrent and local authorities face increasing demand for care services.  They received 1.9 million requests from new clients in 2020/21 in the context of local government spending power reducing by 26% in the 10-year period to 2021.

Clearly the impact of the pandemic is still being felt, but it is encouraging that NHS England was seen to have consulted well in the run up to 1 July 2022 and that it provided resources and helpful guidance through a dedicated platform.  Concerns were raised, however, about an oversight framework that leaned heavily towards traditional measures of NHS performance and had less developed ways of measuring ICS outcomes and success.

Inherent tensions persist between local health and social care strategies and the expectations to meet national access and waiting targets.  These are not mutually exclusive aims – far from it. But the intense focus on the latter risks frustrating much needed progress in the former, particularly on prevention and whole population health management. 

A stark example of these challenges is found in the variation in life expectancy between the most and least deprived areas, this being 9.7 years for men and 7.9 years for women.  More can and should be done to improve cross-government working to address the factors contributing to ill health.  As evidence of this, the February 2022 white paper on levelling up had two of its 12 aims relating to health, but across the 132-page document does not refer to ICSs. 

It is going to take time for ICSs to show their worth. But one step that should help is ensuring oversight arrangements, particularly for integrated care boards, are fully aligned with the strategic objectives for ICSs.  This, coupled with the Department of Health and Social Care and NHS England identifying a realistic set of medium-term objectives, especially in the current circumstances, ought to improve their prospects of success and hopefully strengthen the foundations.

See new story: Tackle pressures to give ICSs best chance of success, says NAO