NHS reform: Integrated Care Systems

The NHS Long Term Plan

Coinciding with the 70th anniversary of the creation of the NHS in 2018, Theresa May asked the NHS in England to produce a 10-year plan to improve access, care and outcomes for patients. The resulting NHS Long Term Plan, published in January 2019, included actions on workforce, technology, innovation and efficiency. It also proposed legislative changes to the ‘system architecture’ of the NHS. Bringing together different NHS organisations, and local councils, into ICSs is seen as central to the delivery of the NHS Long Term Plan. This has been seen as a change to the commissioner/provider split introduced in the early 1990s, and as a move away from some of the market-based reforms of the Health and Social Care Act 2012.

One of the key aims of integration is to reduce hospital admissions, but new models of care have not always led to the expected reduction in demand, and there are challenges in developing a robust evidence base. There is clear evidence for the wider determinants of health – from air quality to housing and education. Joint action across communities will be essential to any plans to prevent ill health and reduce health inequalities.

Integrated Care Systems: A new model for the NHS

ICSs have already developed in 14 areas of England (see map), and new ICSs will replace the remaining 28 Sustainability and Transformation Partnerships (STPs) by 2021. They aim to deliver improvements to care and public health for a defined area (of around 1-3 million people) through ‘population health management’. They also aim to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care.

Two ICSs – Greater Manchester and Surrey Heartlands – have agreed further devolution deals with Government. Alongside the development of ICSs, there is increasing joint working between clinical commissioning groups (CCGs), which commission most local NHS services. Mergers of CCGs have seen the number reduce from 211 in 2013 to 195 now. This process could lead to a single CCG in each ICS area. The Long Term Plan also proposed a new Integrated Care Provider (ICP) contract and the formation of Primary Care Networks (PCNs) (see box).

Integrated Care Provider (ICP) contracts would see a number of local providers coming together to take responsibility for the health services of a defined population. They have yet to be introduced, but NHS England and NHS Improvement have accepted the recommendation of the Health and Social Care Select Committee, that only statutory NHS bodies should hold any future ICP contracts, to allay concerns that they could lead to privatisation.

Primary Care Networks (PCNs) are groups of GP practices that have been established across England. They work together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas, covering populations of around 30-50,000.

Targeted legislation

Following extensive consultation, NHS England and NHS Improvement have recommended the introduction of a Health Service Bill. This would remove barriers to joint working between NHS organisations and their partners, including:

• Introducing a new NHS ‘triple aim’ for better population health, better quality of patient care, and financially sustainable services. This ‘triple aim’ would apply to all NHS organisations, to help them focus on wider, shared responsibilities.
• Changing the exiting NHS competition framework to allow more discretion about when to carry out a formal procurement process for health services.
• Merging NHS England and NHS Improvement to create a single leadership body, combining their respective responsibilities for performance, finance and care transformation.
• Allowing the formation of joint committees so that ICSs can make legally binding decisions.

Do we need to legislate to integrate?

Legislation can remove obstacles to integration, but it cannot force people and organisations to collaborate effectively – this depends on establishing local relationships, goodwill and trust. Greater sharing of responsibilities may mean that regulatory and accountability relationships need to change. Some of this is already happening, with the Care Quality Commission now reviewing local systems, as well as individual providers. Legislation can help avoid legal uncertainty – for example, clarifying what might happen if the decision of an ICS conflicted with the statutory duties of its member organisations.

The experience of local government and the NHS working together has been variable so far. Should legislation specify the level of involvement of local authorities, or other non-NHS bodies, in ICS arrangements? What will be the future of existing forums for promoting joint working, such as Health and Wellbeing Boards? The recent election campaign highlighted the parties’ divergent views about the role of competition and the private sector in healthcare. Even targeted changes to the structure of the NHS will be contested in Parliament.

Further reading

• Evaluating integrated care Why are evaluations not producing the results we expect? Nuffield Trust
• The NHS’s recommendations to Government and Parliament for an NHS Bill, NHS England/NHS Improvement
• Integrated care: our position, King’s Fund, September 2019
• NHS Long-term Plan: legislative proposals, Health and Social Care Committee
• Integrated care: organisations, partnerships and systems, Health and Social Care Committee. The Government response was published in August 2018