An organisational shake-up within the NHS in England is at the heart of a new integrated and collaborative approach to planning and delivering health and social care services. We consider what it means for joint care.
While news of the growing backlog in hospital treatment in England has dominated the headlines, a fundamental shift in the way the country’s health and care system is organised has passed unnoticed by many.
Data from NHS England shows there were 6.8 million people on waiting lists for care at the end of July – up from 4.4 million before the pandemic. In the same month, the Health and Care Act 2022 came into effect, abolishing clinical commissioning groups (CCGs) and replacing them with 42 integrated care systems (ICSs).
The Act reverses the previous emphasis on health and care system organisations working autonomously and often in competition with each other. Instead, says NHS England, ICSs will be local partnerships – made up of the NHS and GPs, local councils, and the voluntary sector – collaborating to plan how best to deliver high-quality and personalised care to meet the needs of local people.
Removing barriers
In doing so, it’s hoped ICSs will help to remove barriers between different parts of the healthcare system, for example, between health and social care, and help health and care professionals to act earlier to prevent illnesses and tackle the causes of ill health, such as poor housing or unemployment.
The now defunct CCGs began moving towards working in this way in 2016, with the introduction of Sustainability and Transformation Plans, and collaboration between health and care organisations reached new levels during the pandemic. NHS England points to valuable lessons learned and positive results as the NHS, councils and charities shared staff and resources to provide joined-up care and support in the face of Covid-19.
The King’s Fund, an independent research institute involved in work relating to the health system in England, broadly welcomes ICSs and a “vision of joined-up services and a system built on collaboration rather than competition”.
It argues that people too often receive “fragmented care from services that are not effectively co-ordinated around their needs”. This can negatively impact their experiences, lead to poorer outcomes and create duplication and inefficiency.
Collaboration over system-wide issues
Anna Charles, who worked as a doctor at Imperial College Healthcare NHS Trust before joining The King’s Fund, points to the all-too-common recent example of ambulances queuing up outside hospitals, waiting to get patients admitted. “Often the cause is a system-wide issue, rather than just down to the hospital,” she says. “The queues will likely be because of challenges discharging people from hospital and that's because of something that's happening in the community, like not enough district nurses or social care available. It is a prime example of where hospital leaders trying to solve a problem alone isn't going to work – you also need the collaboration of local government, which is responsible for social care, and the local community health trust, which is responsible for the district nursing service.”
Integrated care, says The King’s Fund, is particularly important to improving outcomes and experiences of care for the growing numbers of older people and people living with multiple long-term conditions, as both groups use several different services. There are roughly 1.6 million people aged over 85 in the UK and this is projected to double to 3.2 million by 2041, while between 15 and 30% of the population in England are living with one or more long term health conditions.
A key driving force
Improving care for local people is a key driving force for the new ICSs, which cover geographies with populations of around 500,000 to three million people. However, there will be further subdivisions to serve smaller scale ‘places’ or ‘neighbourhoods’ within ICSs.
Each ICS consists of two statutory bodies. One is the Integrated Care Board (ICB), which focuses on core NHS services, with responsibilities including NHS funding, commissioning and workforce planning. The other is the Integrated Care Partnership (ICP), which has a broader focus, covering the ICS strategy, public health, social care and wider issues impacting the health and wellbeing of the local population.
While distinct commissioning and provision responsibilities still formally sit in separate organisations, the division is becoming increasingly blurred, with providers now represented on the ICB. The new Health and Care Act has also removed the requirement for mandatory competitive retendering for services and products. Instead, says NHS England, a ‘provider selection regime’ will be produced to ensure commissioning decisions are “made transparently and fairly, and in the best interests of patients, taxpayers, and the population”.
Healthcare professionals’ perspectives
It’s still early days, but some healthcare professionals have their reservations about ICSs. Dr Peter Young, a former clinical care lead and Primary Care Network (PCN) director who had experience working with a CCG, says: “Our heads are spinning from trying to understand the cross organisational changes and engage with management staff that are regularly reapplying for roles.”
While the merging of three CCGs into one ICS in his region may have cut commissioning costs, from the ground he has not seen any real change as a clinician, adding that partners in social, community care and mental health, in particular, are struggling. Young says the immediate problem has been the “scarcity of adequately trained staff”.
He likes the “simplicity” of the idea of joint commissioning with social care partners but adds: “I think we will struggle to improve care if the partner organisations that work within it are struggling; it will need time. If the ICB can facilitate a ground-up approach to transformation, and adequate resource be directed to where it is most cost effective, it may be more successful.”
The British Medical Association claims there is a “critical lack” of clinical leadership and public health expertise within the ICS set-up, while the Royal College of Nursing says more needs to be done to tackle staff shortages, with 40,000 registered nurse vacancies in the NHS in England alone. The Patients Association has similar concerns about health and social care staffing and wants to see patients have a more active role in the decisions ICSs make about the design and development of services.
Focusing on commonalities
Charles agrees there are challenges for ICSs, and it will take time to see if they can succeed in their aims: “It’s not going to be easy, and it will be an ongoing effort. Collaboration with partners within your ICS can be much harder than just looking down at what’s happening in your organisation, which is what many leaders have been used to for years.”
She says there are also some facts about the different ICS partners that “make collaboration tricky”, adding: “Take accountability, for example, with elected local government leaders looking out to their local voters, while the NHS has a longstanding habit of looking up to national policy.”
The ICSs that will ultimately make it work, according to Charles, are those where partner organisations focus on the things they have in common. “This starts with looking at the data they have and by listening to the communities they serve to identify the health needs of the population.
That way, they often find that although they are different organisations with superficially differently objectives, they are actually trying to achieve the same outcomes for patients.”
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