The transition to a statutory integrated care system (ICS) is laden with complexity. With substantial guidance still to come, taking stock and anticipating the challenges of effecting robust governance is time well spent.
NHS organisations have grappled with the developing marketisation of service provision while simultaneously needing to collaborate to transform services since the 1990s. In this time, they got the worst of both worlds: competition between the same products and services meant the market never worked.
There was also no failure regime and market exit process for struggling providers. Meanwhile, regulation emerged driving standards towards uniformity in the NHS. However, collaboration was difficult given the separate sovereignty of NHS Foundation Trusts and, until recently, a financial regime that paid for activity and volume.
On the back burner
By the middle of the last decade, it was clear this approach was not working. From 2016, there was increasing emphasis on service integration, with tentative measures such as Better Care Funds and Provider Collaboratives encouraging it.
However, the opportunity for legislation to create the conditions for collaboration was pushed back by Brexit. More recently, the need for pandemic management was the barrier.
The emergence of the ICS concept – via Sustainability and Transformation Partnerships (STP) – was a step towards developing a mechanism capable of delivering services collectively, while balancing the individual sovereignty of NHS organisations. And in so doing, build a broader, more forward-looking approach to people's health.
Responding to the new ICS framework
The government has now published its design framework for integrated care systems, providing a little more clarity around the role of organisations within a statutory ICS.
It defines the ICS partnership as a committee, not a corporate body. It functions to bring together NHS organisations, local authorities and the voluntary, community and social enterprise sector to serve people in a given location.
Meanwhile, the ICS NHS body will be a statutory organisation with a unitary board, with its responsibilities for the NHS services within the ICS.
It will also have responsibility for establishing governance arrangements to support collective accountability for the whole system's performance. The design framework stipulates these arrangements in terms of non-executive and executive roles, and a committee structure.
There's no intention to overprescribe roles and functions. But, prescribed or otherwise, the transition from separate sovereignty to collaboration, integration, and working to a higher set of common objectives will be encouraged but not wholly achieved by legislation.
Ahead of legislation in 2022, the framework allows individual unitary boards to prepare and develop processes and conventions that enable effective collaboration between local partnering organisations. Meanwhile, NHS England will be looking for some common principles across all unitary board development.
There are three issues to consider here.
1 Transparency as the foundation of trust
The question runs across finance, operations, quality and workforce, and there are three concepts to think about in achieving that:
1 A single version of the truth
2 Interpreting this in the same way
3 Agreeing to act on it together
A single version of the truth is a simple statement, but behind that are the assumptions that all bodies will record everything. Not to mention that they will also record things in the same way and get a single presentation of their accounting treatment, operating activity, and quality position.
In the past year, we've supported clients who've discovered the difference between their information department records and the handwritten notes recorded locally, whose data often never make it into the system.
We've also helped other clients improve their clinical coding accuracy so that it matches their peers. And we have conducted enough reviews of financial governance to understand that differences of interpretation aren't unusual.
It needs to be understood that transitions may require a great deal of preparation to achieve the transparency that can be the basis of trust that enables collaboration without partners being refused entry into the 'commercial in confidence' territory.
2 Accountability for ICS NEDs
The new unitary boards will comprise the CEO, finance, medical and nursing directors, and a minimum of three non-executive directors (NEDs) with no ties to other NHS or care organisations. They'll sit alongside at least three representatives from partner organisations in the ICS.
This creates the link back to the separately sovereign trusts within the ICS footprint. As we saw with some of the STPs that preceded the ICS, there's a possibility these arrangements go no further than uneasy compromise as individual trusts defend their interests.
As a result, this should challenge unitary boards to create processes and generate the alignment for accountability to the system.
The subsequent guidance to the design framework will need to consider more questions here:
- While the impulse is towards collaboration, how does this become an incentive?
- How do ICS leaders align their trust counterparts to a set of objectives beyond the individual organisation?
- How do the providers move beyond collaboration to change plans which may disadvantage them?
- How do they engage between themselves but also with their colleagues in the primary care networks?
Understanding the patients an ICS caters to
I think the answer lies in creating an effective clinical strategy and a process of engagement that brings all constituencies together, not to defend their organisations, but to co-develop the opportunity provided by science and technology and insight from data.
For example, we've started to see this in population health management work in Nottinghamshire. A more-targeted understanding of what is going on in vulnerable population groups helps rebuild the pathways around patient and carer interests. In turn, this impels clinical leaders to approach radical new models to shift care into the channels where it is needed.
Effectively, the rules of engagement and the sense of responsibility are shifting. This creates accountability beyond the individual organisation.
This isn't original to the NHS, which should make it less scary. When I first moved into advisory work in 2012, I encountered remarkable work in the Netherlands (in Friesland) on shifting services out of and between hospitals. The view from the clinicians was that it was something they should have been doing 10 years before.
3 How do we define and manage risk for ICS?
Of course, if strategy work produces radical solutions, there will be risks for the partners, such as financial loss, reduced activity, new roles within the system and performance risk.
Each ICS will need to go through risk identification and mitigation planning in the normal way. But the ICS should also see itself as a risk-pooling body. If it has the responsibility for financial allocation, it should retain funds for the transition, so that providers can exit or develop services.
Similarly, the ICS should agree with providers to pool the workforce where new roles and new settings for work are likely. Ultimately, the ICS can become a single market – to coin a phrase – for the movement of money and people. If we can get to this position, a genuine transformation of the NHS becomes a reachable goal.
Addressing all these considerations will take us beyond the anatomy of the ICS (what parts has it got?) to their physiology: how the parts work more-effectively together. That will be the critical thinking that goes beyond the governance towards achieving what needs to be done.
For further information on ICS governance, contact Christine Armistead.
