Comment / Time to focus on ICS priorities

In less than a year, we are aiming to move integrated care systems (ICSs) onto a statutory footing. Time is tight as we deal with the pandemic, elective recovery and underlying financial challenges. With so much change and so much to think about, we need to be clear on what the important things are that finance leaders need to focus on now.

The ambition to move to statutory ICSs is absolutely the right direction, effectively signalling an end to payment by results. This more collaborative way of working is a natural step forward for many, particularly for us at Greater Manchester since devolution.

However, this move is not easy. There remain challenges that still need to be tackled such as being clear about organisational accountability versus system role. There remains a lack of recognition of local authorities’ role in addressing wider determinants of health and overall care pathways. And in general a significant cultural change will be needed. ICSs face very specific issues depending on their size, geography and history.

It is true that there is no ‘one size fits all’ model for an ICS, and things will evolve over time. However, we all share common priorities. These can be considered in five categories – areas for clarification; transition management; oversight; financial planning; and wider partnership working.

First, clarity is needed over ICS roles and responsibilities – what is the role of the ICS NHS body and the role of the ICS health and care partnership? Statutory functions of the ICS need to be confirmed, including what and when current NHS England responsibilities will move to the ICS NHS body. Clarification is also needed on the ICS financial regime, including how funding will flow to place level, provider collaboratives, GPs, and other primary care providers.

Mechanisms are needed to ensure the focus is on cost and value. As an ICS this must be our priority over the next couple of years alongside recovery.

We also need to understand more about the role of provider collaboratives and place, particularly in terms of: their financial responsibilities; how they will be resourced, governed and held to account; and how they will they work with primary care. How we set up these arrangements can fundamentally affect how people behave, and we need to carefully think this through as we design the details of system working.

Second, another immediate ICS priority must be transition management – in terms of new systems and structures, as well as supporting staff including finance teams. This includes a raft of practical requirements such as closedown of clinical commissioning groups, transfer of ledger, contract arrangements and workforce issues. Supporting commissioning staff through the transition and ensuring the required staff, skills, leadership, learning and development is in place for ICSs are key issues. This all takes time and capacity – both of which are in short supply.    

Third, the approach to financial oversight will also impact on how ICSs evolve. The oversight roles of NHS England and NHS Improvement – both national and regional – ICSs and the Care Quality Commission, need to be aligned and understood, particularly in terms of how this works across place and provider collaboratives. We also need to understand the duty to collaborate – how will this be defined, measured and acted upon?

And fourth, in terms of system financial planning, we need to create a longer-term approach that aligns activity, finance and workforce, while reducing the complexity of the planning process. This will include a capital strategy that works for organisations that span more than one ICS.   

Lastly, but perhaps the ultimate priority, is how to quickly make a reality of working more closely with local government and other partners to tackle the wider social determinants of health, and the broader issue of health inequalities. It can sometimes feel as though we are spending too much time on how money will flow between organisations and not enough on how we get the best value or reduce costs across the whole system. We must not lose sight of the reason we are making these changes – to create a simplified approach that brings all the money together to address the key issues impacting on population health.

There is a lot to do and it won’t be easy or straightforward. And there is not a lot of time, so we need to motor on over the summer. We need to recognise capacity is tight and there are other urgent calls on our time. But as a group of finance professionals we can work together to focus on what matters most.

I am encouraged by many of the conversations I am having with colleagues. Last month I chaired an energetic HFMA roundtable to discuss what a system finance framework should look like and the behaviours that would be needed to make it work. This month I took on the chair role of the HFMA System Finance Special Interest Group – focused on raising awareness of issues, supporting NHS England and NHS Improvement in the testing of ideas, and providing guidance for NHS finance staff.

Financial leadership is critical to system success. So, I was pleased to hear, at that meeting, NHS England and NHS Improvement emphasise the importance of engaging with the finance community as system finance and governance arrangements develop. I have had the opportunity to help shape and create some of the guidance due to be published to address a number of these issues and am reassured by the engagement processes. It’s great to meet up with colleagues from all over the country, faces old and new, all with the determination to help the national team ensure this guidance supports us deliver improved outcomes for our population.

Claire Yarwood is chief finance officer at Manchester Health and Care Commissioning