Integrating care: Next steps to building strong and effective integrated care systems

This briefing:

• Summarises the proposals of relevance to local government in the NHS consultation document.
• Highlights the initial key messages, questions and concerns of the LGA. Our final response to the consultation will be informed by the views of our member authorities.
• Encourages councils to respond to the consultation, in their own right and with their system partners to ensure that local government provides a strong and clear voice on the future of health and care partnerships. 

Placing ICSs on a legal footing and the form the legal entity will take will have an impact on existing partnerships between the NHS and local government. We urge councils to submit responses in their own right and as partners in health and care systems. The proposals should build on the strong and effective partnerships that already exist between the NHS, local government and other key partners. 

We support the direction of travel of the proposals towards an integrated health and care, based on collaboration not competition, and the principle of subsidiarity in decision-making. The swift and effective action of local government and the NHS during the pandemic has demonstrated the importance of collaboration between the NHS, local government and other key partners.

We support the objectives but we have questions about how the changes will play out in practice. It is unclear whether this really does represent a step change in the NHS moving from a centralised, command and control organisation to one in which power and resources will be devolved to systems and places. Does this really represent devolution of power and resources or is it simply delegation of functions within a tight framework determined at the national level, and where ICSs effectively bypass or replace existing place-based collaborative partnerships for health and wellbeing?

Statutory reform of ICSs: The document outlines two options for placing ICSs on a statutory footing: creating them as statutory joint committee, bringing together current statutory organisations; or a statutory corporate NHS body which includes current CCG functions. The consultation document has a clear preference for option two. There would be local government representation in each option but the nature of the relationship between the NHS and local government will be affected by the legal form the Board takes. For this reason, we support ICSs becoming a statutory joint committee in which local authorities are equal partners. Whatever the final outcome of the consultation, we need clarity on ICS legal form and whether this will the main vehicle for local government and NHS partnerships. Our call for a reciprocal duty of cooperation on the NHS and local government to address health inequalities requires a real partnership that includes but goes beyond local government representation on a corporate NHS body.

We are clear that most commissioning will still need to be at place level: Some councils are concerned that ICSs may withdraw commissioning capacity at place level. This would not be helpful in commissioning appropriate, effective and joined up health and care services.

With regard to NHS services being removed from the scope of the Public Contracts Regulations 2015 we support local government and the NHS operating within the same legal framework wherever possible. Local government is subject to the Public Contracts Regulations so this proposal represents greater regulatory burden on local government. We would be concerned if this difference created a barrier to existing or new joint commissioning arrangements, or if commissioning was inappropriately channelled through the NHS. 

Values and principles underpinning the proposals: The LGA, the NHS Confederation, NHS Clinical Commissioners, NHS Providers, ADASS and ADPH published joint principles that must underpin effective integrated care. They are:

• collaborative leadership
• subsidiarity - decision-making as close to communities as possible
• building on existing, successful local arrangements
• a person-centred and co-productive approach
• a preventative, assets-based and population-health management approach
• achieving best value.

Some of these principles feature strongly in the consultation document, in particular collaborative leadership, subsidiarity, and achieving best value. We are keen to work closely with NHSEI to ensure that all of these principles underpin integrated working in all areas. 

Maturity and capacity of STPs and PCNs. We are in favour of ICSs with strong collaborative leadership, a commitment to devolving to place, and a focus on improving population health outcomes. Some areas are already making steady progress. But not all system partnerships have operationalised the above principles. Immature systems may rely heavily on regional or national direction to undertake their new role. We are concerned that this reliance may end up being hard-wired into some systems. LGA is working with NHSEI to further develop a sector-led approach to system leadership underpinned by the values at the heart of the reform – place, population health, collaboration. We propose a more evolutionary approach to ICSs which would avoid immature systems being burdened with duties that they do not have the capacity to carry out effectively. Even if ICSs are created in all parts of England by April, they should not be given powers and duties until they have demonstrated maturity, competence and partnership and this assessment should involve local government partners.

In support of greater integration, place based working and local accountability, the LGA is calling on the government to introduce:

• a new reciprocal “duty of collaboration to improve population health and address health inequalities” on all NHS organisations and local authorities
• a legal requirement on ICSs to involve health and wellbeing boards (HWBs) in the development of plans and to devolve the development of place or locality plans to HWBs
• a new duty for HWBs to ‘sign off’ on all ICS plans
• commissioning to continue to have a strong place-based focus, with a strong and proactive role in HWBs in approving commissioning plans
• a duty on ICSs to be accountable to their local communities through existing democratic processes. 

The consultation document sets out the future of integrated care systems (ICSs) and outlines two options for ICSs to become legal entities by April 2022, subject to legal reform. NHSEI is inviting views on the proposed legislative options by Friday 8 January 2021.

The document builds on the NHS Long Term Plan and outlines proposals to promote greater collaboration between NHS bodies and between NHS and other partners to:

• improve population health and healthcare
• address inequalities in health and outcomes
• enhance productivity and value for money
• and help NHS to support broader social and economic development.

Integrated care systems (ICSs) will lead stronger partnerships in local places between NHS, local government and others with a greater role for primary care; provider collaboration; strategic outcome-based commissioning; and connecting data across providers and commissioning.

The document gives a commitment to devolution of functions and resources – including planning, commissioning and organisation of some specialised services, and to devolve greater share of primary care funding and improvement resource. There is also a focus on place – for most ICSs, place will mean local authority boundaries. There is recognition that economies of scale may need more strategic commissioning and delivery at ICS, regional or even national level.

LGA comments, questions and messages on Purpose

• We strongly support the general policy direction: towards greater collaboration between NHS organisations and across the NHS and local government; a strong focus on population health and addressing health inequalities; a strong focus on place as the level at which change happens; a clear recognition that local government are key partners in this transformation.
• Compared with the NHS Long Term Plan, which barely mentioned the role of place and the importance of collaborative partnership between local government and the NHS, this document represents a significant change in approach, which we welcome. That said, there is little explicit recognition of existing effective place-based partnerships, for example, health and wellbeing boards.
• It is difficult to foresee how the relationship between national, regional, system, place and neighbourhood will play out in practice. It is not clear whether there will be genuine devolution of decision-making and resources to the most local appropriate level, or this will be limited to delegation from the national and regional tiers of NHSE and will stop at ICS level. It is also difficult to predict whether this represents true devolution of power and resources or whether it is simply delegation within a tightly controlled national framework.

This section sets out specific proposals for moving to system working by April 2022. They are summarised below.

Provider collaboratives will join up services within and between systems to improve quality, sustainability, reduce unwarranted variation and outcomes, reduce health inequalities, improve workforce planning and ensure effective use of resources. All NHS provider trusts will be expected to be part of at least one provider collaborative by April 2022. NHSEI will publish further guidance on potential models in early 2021.

Place-based partnerships – there will be a named place leader who will work with local authorities and the voluntary sector to: support and develop primary care networks; join up health and care; identify and prioritise at-risk communities by use of population health data; and coordinate the NHS contribution to wider health, social and economic development strategies in place. The document also includes an explicit commitment to work more closely with local government and to devolve resources and funding to place level where: “partnership working is truly embedded and matured”.

Clinical and professional leadership – ICSs will be expected to embed system-wide clinical and professional leadership their partnership board and various other governance structures. Primary care networks will need to have representation at all level, including in ICS governance arrangements.

Governance and accountability – the document commits to mutually agreed governance arrangements, including the partnership board. The NHS, local government and other partners will have collective responsibility and decision-making in assurance, planning and improvement and financial governance. The system must also define leadership, governance and accountability arrangements for place, which should involve: “at a minimum primary care providers leadership, local authorities, including the Director of Public Health and providers of community and mental health services and Healthwatch; agreed decision-making arrangements with local government; and representation on the ICS board.”

Financial framework – increasingly, NHSEI organise and allocate finances at the ICS level, and delegate allocative decisions to local leaders, in line with national rules and locally-agreed strategies. A single pot, bringing together funding for CCG commissioning budgets, primary care budgets, most specialised commission funding, central sustainability funding and nationally-held transformation funding, will be held by systems. “Decisions about the use of all these budgets will usually be made at the lowest possible level, closest to the communities they serve and in partnership with their local authority”. Increasingly, funding will focus more on outcomes than activity.

There are also specific proposals to remove NHS services and institutions from the scope of the Public Contract Regulations 2015.

• Data and digital - ICS Boards will lead system-wide transformation to increase digital and data literacy of workforce, and invest in infrastructure. This will include connecting health and care services, better use of shared data to transform care and also to increase person-centred care.
• Regulation and oversight – national regulators will have a greater focus on systems and the effectiveness of partnership working, though they will still regulate individual institutions within systems.
• How commissioning will change – the document outlines the key changes to commissioning. There will be a system-wide approach to strategic commissioning; provider collaboratives and partnerships will be a driver for transformation; and there will be a greater focusing on commissioning for outcomes. In partnership with local authorities, ICSs will consider what can be commissioned at place. ICSs will have a greater role in specialised commissioning- if at the appropriate scale - within national service specifications. Funding for specialised services will shift from provider based allocations to population based budgets.

LGA comments, questions and messages on Putting this into practice

• We welcome the recognition of the role of local government and the need to work at place. However, there is no specific commitment to build on what exists – for example, existing integrated care partnerships and health and wellbeing boards.
• With regards to the defining local places, it is crucial that this is done in partnership and with agreement of local councils, including district councils in two-tier areas. We also welcome clarification as to whether there will be one place leader for the whole of the ICS or, in areas where the ICS spans more than one council, whether there will be a specific leader for each place.
• It is disappointing that there is little consideration of wellbeing, the wider determinants of health or the role of councils in relation to economic and social drivers of health and wellbeing.
• We support closer working between providers and commissioners to plan and deliver better outcomes. We are also keen to support greater parity between providers – both within NHS between acute, mental health, primary care etc – and between the NHS and other partners, especially between the NHS and social care providers. It is only be working together as equal partners that we can develop truly joined up and person-centred care pathways that avoid the need for inpatient treatment. It is also important for NHSE to give a clear expectation on ICSs that places will commission services best suited to place level commissioning.
• With regard to governance and accountability – We urge NHSE to build on existing place-based accountability arrangements, including councils, health and wellbeing boards and health overview and scrutiny. It is important that any additional governance arrangements adds to, rather than duplicates or bypasses existing arrangements. We also urge the NHS to work with local government partners to ensure that accountabilities within systems are as simple as possible and facilitate joint working towards a shared objective. 
• Joining up finances in a single pot to facilitate greater flow across the health and care system is welcome. We also welcome the commitment that ICSs will allocate resources according to national frameworks and local priorities. But how will they balance the two? And will there be a tension between national and local priorities? Greater clarity is needed.
• With regard to the Public Contracts Regulations 2015, – the proposal to remove the NHS from the scope of the 2015 regulation was included in the previous Bill, which fell in 2019 due to the general election. We strongly call for local government and the NHS to operate within the same legal framework wherever possible. This proposal would lead to a lack of alignment between NHS and councils which might be a challenge for joint commissioning. NHSE will need to work with local government to consider the implications of this lack of alignment .
• We urge NHSE to adapt the joint principles for effective integrated working agreed by LGA, the NHS Confederation, NHS Clinical Commissioners, NHS Providers, ADASS and ADPH. They are:
  • collaborative leadership
  • subsidiarity - decision-making as close to communities as possible
  • building on existing, successful local arrangements
  • a person-centred and co-productive approach
  • a preventative, assets-based and population-health management approach
  • achieving best value.
• Some of these principles feature strongly in the consultation document - collaborative leadership, subsidiarity, and achieving best value. However, the proposal to make ICSs a Statutory Corporate NHS body many undermine the commitment to collaborative and equal partnerships between the NHS and local government. There is little concrete commitment to a person-centred and co-productive approach, and adopting a preventative, assets-based approach. There is almost no recognition of existing local arrangements and building on these rather than creating new structures. This is disappointing and, should we encourage more explicit recognition of HWBs as key building blocks of ICSs.
• The LGA are calling on the government to:
  • introduce a new reciprocal “duty of collaboration to improve population health and address health inequalities” on all NHS organisations and local authorities.
  • a legal requirement on ICSs to involve health and wellbeing boards (HWBs) in the development of plans and to devolve the development of place or locality plans to HWBs.
  • a new duty for HWBs to ‘sign off’ on all ICS plans
  • commissioning to continue to have a strong place-based focus, with a strong and proactive role in HWBs in approving commissioning plans.
  • a duty on ICSs to be accountable to their local communities through existing democratic processes. 

The document restates the NHSEI recommendations to the government on legal reform made in 2019, and which formed the basis of the NHS Bill 2019 (which fell due to a general election being called). It also includes two options for creating a legal framework for ICSs.

• Option 1 – A statutory ICS board or joint committee with an accountable officer, recognised in legislation. This partnership would bring together statutory organisations – NHS commissioners, providers and local authorities – to enable them to take decisions collectively.
• Option 2 – ICSs will become a statutory corporate NHS body, into which current CCG commissioning functions would be transferred. CCGs would be abolished and replaced by a board with representation from system partners, including local government. As a minimum, membership would include representatives of NHS providers, primary care and local government. 

The consultation documents seek views on four specific questions:

• Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
• Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
• Do you agree that, other than mandatory participation of NHS bodies and local authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?
• Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSEI should be either transferred or delegated to ICS bodies?

LGA comments, questions and messages on legislative proposals

• The LGA strongly believe that the ICSs should be a partnership of equals between local government and the NHS. This may be more difficult if ICSs are statutory corporate NHS bodies with commissioning functions.
• In the original legislation, ICS were proposed as ‘voluntary joint committees’, which the LGA strongly supported.  Both options go beyond ‘voluntary joint committees’ and make ICSs mandatory for all areas. We broadly support this mandation to partnership working
• Local government must have a strong and clear role shaping services across healthcare, social care, prevention and the wider determinants of health whatever option is adopted. 
• With regard to the four specific questions, the LGA is keen to hear the views of councils in shaping our responses. Our initial views are as follows:
  • A statutory footing for ICSs – We supported the proposal in the original legislation to for ICSs to be voluntary joint committees. However, we do recognise that progress toward system working needs greater impetus which mandation will bring. We therefore support making ICSs mandatory in all areas but recognise that this legal requirement will need to be backed up with support for system leaders to work collaboratively, with a focus on achieving population health outcomes and to devolve power and resources to place wherever appropriate. We seriously question whether all systems will have sufficient maturity and capacity to take on the wide-ranging responsibilities of ICS by April 2022. We propose that ICSs should not be given powers and duties until they have demonstrated maturity, competence and partnership with local government.
  • Do you agree Option 2 offers greater incentives for collaboration and accountability – It is clear that NHSEI favour Option 2 – ICS becoming a Corporate Statutory NHS body into which CCG commissioning functions are transferred. The LGA has real doubts whether it will be possible for local government to be an equal partner under option 2 arrangements. It is hard to see how a corporate statutory NHS body can be a partnership body which relates to all constituents in the health and care system. We are concerned that if Option 2 is adopted systems will lose the wider perspective from local government, on the role of social care, public health, housing, early years and other local government functions in ICS plans and strategies. We propose that the best option to preserve and promote equal partnerships is to create system level integrated commissioning NHS bodies and also have statutory joint committees to which ICSs are accountable to ensure they deliver integration at place within the system.
  • Systems to shape their own governance arrangements – We strongly support systems the having the freedom and flexibility to determine their own membership, beyond the statutory minimum. We would like to see a stronger emphasis on ensuring the system governance arrangements build on and enhance existing place and neighbourhood governance arrangements. They should not bypass, undermine or duplicate existing governance arrangements at place.  In particular, they should ensure that HWBs remain the key place based decision-making body.
  • Delegation of HSEI commissioning to ICSs – We strongly support delegation of NHSEI commissioning to ICSs, where appropriate. Furthermore, there needs to be an equal emphasis on and commitment to delegating any commissioning that can be down to place level, ensuring the application of the principle of subsidiarity. 

• NHSEI will support systems to take on the additional roles by April 2022, according to the implementation plans produced by each ICS. There will also be support to develop collaborative leadership.
• All systems to be ICSs from April 2021. By April 2021, all ICSs will agree with the NHSEI regional director how to meet current operating arrangements and planning for Covid-19 response. By September 2021, ICSs will agree with regional directors their implementation plans for taking on their new role legal duties.

LGA comments, questions and messages on transition and next steps

Our own final response to the consultation will be informed by the views of our member councils – if you have anything you wish to share with us at  this stage please email [email protected].