LGA response to the Hewitt Review of ICS accountability and autonomy

• Let local leaders lead – we recognise that the Government and its national agencies lead the policy agenda for ICSs and, as such, it is appropriate that they should set a small number of high level and strategic priorities for ICSs. These should be focused on outcomes rather than process or activity. For example, setting targets for addressing health inequalities, to improve health and wellbeing outcomes, to improve access to health, care and wellbeing services and support. This will give local leaders of ICSs and place-based partnerships, including health and wellbeing boards, the space and flexibility to focus on the priorities that are most important for their communities.
• Don’t reinvent the wheel – build on the effective working of health and wellbeing boards (HWBs) and other existing place-based partnerships rather than bypassing or duplicating them.  We are not starting from scratch. Many areas have been working for many years and to join up care and support to achieve better services and better outcomes. We need to learn from them and, where they are working, leave them to get on with the job.
• The principles of subsidiarity and devolution don’t stop at ICS level – we recognise that ICSs potentially represent a major delegation or devolution of resources and responsibilities for the NHS, moving from a top-down, centrally driven institution to one in which the 42 ICSs are the local leaders. But ICSs also need to devolve power, decision-making and resources to the most local level appropriate. In many cases, this will be the place and neighbourhoods defined by local government places. Local authorities are the natural leaders of place. We already have HWBs at place level responsible for identifying local priorities and agreeing shared strategies for achieving better health and wellbeing outcomes – ICSs need to support and enable them rather than duplicating or bypassing them.  
• Accountability upwards to NHS England and Government is important but so too is accountability outward to local citizens – elected members have a vital part to play in this. For too long there has been a democratic deficit in the NHS. ICSs need to work closely with councils and their elected members to ensure that their priorities in the integrated care strategies and plans for services in the Joint Forward Plans reflect local needs, concerns and aspirations in a clear set of local ambitions for all partners.   The role of local authority overview and scrutiny also makes a major contribution to ensuring that the NHS is locally accountable. 
• Promote and embed a learning culture – at all levels. It’s not about telling people what to do or promoting a single approach in all ICSs or places but everyone committing to promoting a learning culture. NHSE and DHSC can support this by promoting a peer-led approach for ICSs, such as the one developed by the LGA to drive improvement in councils.  We already co-produce and jointly deliver a peer-led support programme for systems and places in partnership with NHS Confederation and NHS Providers. We are keen to work with DHSC and NHSE to further extend the peer-led approach.
• Role of regulators – we welcome that the Review considers the role of national regulators in an increasingly complex assurance and oversight framework for health and care providers and commissioners.   In addition to providing assurance of care and health providers, the Care Quality Commission (CQC) is required to assess the ICSs and local authority adult social care functions.  The sequencing and interrelationship between provider, adult social care commissioning and ICS assessments is complex and has yet to be clarified.  The LGA is working with CQC to develop both new assurance frameworks, but it remains to be seen how all three will work together in practice. The role of system oversight and/or ICS assurance should not solely be about identifying areas of poor performance. It also has a role in identifying and promoting best/good practice as part of wider efforts for continual learning and improvement.
• Recognise diversity – while there is no ‘one size fits all’ template for effective integration in all areas, there is no doubt that we can learn from each other, through peer-led improvement. We are keen to work with DHSC and NHSE to identify and share the diversity of good practice currently being developed.

This peer support programme is an excellent opportunity to step back and take stock with people who have real experience and credibility. But it’s not for the faint hearted – we must be willing to hear the hard truth and to then act accordingly. Change is uncomfortable but necessary and this programme helps us to achieve real transformation. 

Dame Gill Morgan, Chair Gloucestershire ICS

Empowering local leaders

Question 1: What are the best examples, within the health and care system, where local leaders and organisations have created transformational change in the way they provide services or work with residents to improve people’s lives? Examples can be from a neighbourhood, place or system level.

LGA response

The LGA has an established track record of identifying the examples of good practice on the integration of planning and delivery of services to improve people’s lives. Because the LGA represents councils, most of our good practice relates to the level at which councils operate and therefore is at place-level. ‘What a difference a place makes: the growing impact of health and wellbeing boards,’ published in July 2019, identified 22 health and wellbeing boards (HWB) and one integrated care system that were making strong progress with working across the NHS, local government and the community and voluntary sector (CVS) to make a real difference in their places.

We have selected just a few examples from this document here but all the examples are available on our website.

Integrated commissioning and provision in Plymouth - the HWB has overseen the establishment of integrated commissioning in Plymouth, with an integrated fund, and risk and benefits sharing arrangements. Joint commissioners are co-located and work as a single team under a director of integrated commissioning. Most adult social care services have been transferred to Livewell South West, an integrated community health and care provider with a single point of access, locality-based services and improved secondary care discharge pathways. The integrated service has helped the adult social care budget achieve balance for four years in a row, while also achieving good outcomes and satisfaction ratings.

Sutton Health and Care at Home integrated provider alliance - the alliance was jointly commissioned in 2018 as a contractual joint venture to deliver the HWB priority of enabling people to live well in their own homes. The alliance covers NHS providers, the council and the GP federation, and aims to reduce non-elective admissions and enable patients to be discharged safely from hospital as quickly as possible. It has been live for less than a year, but already performance indicators are improving despite growing demand, and compare favourably with comparator areas:

• non-elective admissions for over 65s – reduced by 1 per cent
• length of stay for over 65s – fell by 6 per cent
• average length of stay in hospital – cut by 5 per cent
• the proportion of older people remaining at home 91 days after reablement continues to increase year-on-year with a current target of 95 per cent.

General learning and messages on enablers of transformational leadership

Over many years, we have worked with councils, the NHS and other local partners to identify the critical success factors for effective joined up working. In 2019, the NHS Confederation, NHS Providers, ADASS and ADPH pooled our insights into joined up working to identify the key principles that are essential to effective integration. Whether working at national, regional, system, place or neighbourhood level, effective partnership working on health, care and wellbeing should have the following elements:

• 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.

The LGA and the Social Care Institute for Excellence has also published Achieving Integrated Care which identifies 15 actions and good practice that partners can take.

In November 2022,  NHS Confederation and LGA published top tips for developing integrated care strategies, distilled from the early lessons from integrated care partnerships. The essential elements are:

• a shared vision
• co-production and including people with lived experience
• keep communication open and adopt a ‘you said, we did’ approach to demonstrate that people’s views have influenced policies and strategies
• develop agendas and materials together – with all partners
• inclusive language – use ‘we’, ‘us’ and ‘our’ and be clear about who is included in ‘us’
• inclusive leadership – to communicate the vision, listen and learn from others and drive forward joint working.

Question 2: What examples are there of local, regional or national policy frameworks, policies, and support mechanisms that enable or make it difficult for local leaders and, in particular, ICSs to achieve their goals?

LGA response

This is an incredibly broad question, covering all policy frameworks and support mechanisms across health, social care, and wellbeing so it is difficult to assess the value of each one.  

With regard to policy frameworks, it is not so much a question of whether individual policy frameworks and support mechanisms help or hinder local leaders but the sheer number and complexity of the policy landscape for different parts of the system that hinders local leaders from being able to focus on shared goals for improving population health.  For example, there are three separate but overlapping outcome frameworks for the NHS, adult social care and public health. The integration white paper, published in February 2022, proposed an additional shared outcomes framework for integration. 

The LGA has long argued for a single outcomes framework to provide much needed clarity on what the Government expects all partners in systems to achieve together. We recognise that the Government lead the policy agenda for ICSs and as such, it is appropriate that they should set a small number of high level and strategic targets for ICSs. These should be focused on outcomes rather than process or activity. For example, setting targets for addressing health inequalities, to improve health and wellbeing outcomes, to improve access to health, care and wellbeing services and support.

The Health and Care Act 2022 establishes the legal basis for Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs) and we have consistently supported the Government’s light touch, flexible and enabling approach to give systems and places the flexibility to make their own arrangements for joining up care and support and set their own priorities and strategies for improving population health.  We also support subsequent statutory guidance for health and wellbeing boards (HWBs) which emphasises that ICSs need to work with and enable HWBs to continue to be effective leaders of place. Furthermore, HWBs and ICSs need to work together to ensure that they are clear about how each make a unique contribution to joining up care and support to improve population health outcomes and address health inequalities.  

With regard to support mechanisms, the LGA has developed a highly regarded sector-led improvement (SLI) approach in which all councils have an individual and collective commitment to continuous improvement.  The LGA co-produces well-regarded and effective peer-led improvement support programme with NHS Providers and NHS Confederation at neighbourhood, place and/or system level – Leading Integration Peer Support and place level Leading Healthier Places. Both support programmes include the following components:

• peer led – drawing on the experience and expertise of senior leaders in local government, the NHS, the community and voluntary sector to act as ‘critical friends’ and to facilitate, advise and challenge local leaders
• on-site and virtual peer reviews and challenges, development session, best practice workshops, critical friend support
• free and open to any health and care partnership at system, place or locality
• flexible and tailored but can also provide ‘off the peg’ resources, including self-assessment frameworks, good practice case studies and policy briefings.

There is already a wide variety of support offers available to system leaders so we recommend that the Review considers how we can ensure that all support is based on a commitment to continuous improvement and learning, and helps systems identify the most appropriate support for their particular needs.

The LGA has also published four high impact change models (HICM) which identify the actions that can maximise the effectiveness of care and support:

• Managing transfers of care between hospitals and home. 
• Reducing preventable admissions to hospital and long-term care
• Improving health and wellbeing through housing
• Achieving integrated care through community and neighbourhood working.

The HICM on managing transfers of care is now a national condition of the Better Care Fund policy framework which underpins the hospital discharge policy and frames ongoing work such as the NHS’s recent 100 day challenge.

Question 3: What would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals?

LGA response

It is important for the Review to explicitly recognise that ICSs are not NHS bodies: they encompass NHS organisations, local authorities, health and care providers, the community and voluntary sector and community representatives. Even ICBs, which are statutory NHS bodies, are required to have at least a local authority partner member, and many have gone beyond the statutory requirements to include more than one LA partner member. Integrated Care Partnerships are very clearly an equal partnership between ICBs and local authorities.  ICSs need freedom and flexibility from rigid activity and performance targets to be able to innovate. They also need the following freedoms and flexibilities.

• An enabling culture – which gives permission to systems and all partners within them to do things differently in order to make an impact on population health and health inequalities. The ICP strategy sets the ‘what,’ giving local partners – including HWBs and place-based partnerships - the freedom on the ‘how.’  This approach needs to be actively promoted by all leaders at all levels of systems and the organisations within them – from the way an ICS works with partners to design new joined up services to allowing frontline workers within organisations to change the way professionals support individuals. This enabling and flexible culture should extend across all integrated care policy and action, for example the Better Care Fund.
• Clarity on the must dos and minimum standards – all people at all levels need clarity on the minimum standards of safety and quality and their legal duties in which they operate. 
• A focus on shared outcomes – so that commissioners and providers have the freedom to innovate in how they plan and deliver care and support in pursuit of shared outcomes. Focusing on activity or processes over outcomes limits local action to make a positive difference.
• Data sharing needs to be the norm to underpin truly integrated health and care. However, the approach needs to work for all stakeholders, including citizens, and must not be driven by the needs of one sector. Legislation, governance, guidance and system architecture must be designed to support effective information sharing and not create unnecessary barriers.
• A co-productive approach – in which commissioners and providers of care and support listen to and act on the views of people with lived experience of services and on what will make the most difference to their health and wellbeing. Often, the most innovative and effective ideas come from the people who draw on or directly provide care and support.
• A learning culture – in which places, systems, regional and national partners actively share information about what has been effective in improving outcomes for people and communities, and what has not worked. 
• Permission to take risks and fail – by definition, innovation requires risk-taking and risk-taking sometimes doesn’t succeed.  Partners need to be clear about each other’s appetite for risk and agree how innovative they are prepared to be. They must also have clarity from local, system and national agencies and regulators what consequences there will be if innovations fail to deliver the anticipated outcomes and improvements.
• Recognition of diversity – what works in one neighbourhood, place or system may not be effective elsewhere. We need to maintain the approach that there is no ‘one size fits all’ approach where an innovative approach in one area develops into a national template. That said, national organisations can support local places and system leaders to draw out the critical success factors and essential components that are common to innovative approaches.

Question 4: What local, regional or national policy frameworks, regulations and support mechanisms could best support the active involvement of partners, including adult social care, children’s social care services and voluntary, community and social enterprise (VCSE) in integrated care systems?

LGA response

Again, this is another broad question covering policy frameworks, regulation and support mechanisms.  Below we identify the existing components of the policy which support an inclusive approach.

• Health and Wellbeing Boards (HWBs) – already exist as place-based forums in which clinical, political, professional and community leaders come together as equal partners to assess the health and wellbeing needs of their communities (through the joint strategic needs assessment) and agree a shared strategy for improving health and wellbeing (through the joint local health and wellbeing strategy).
• Joint Strategic Needs Assessments (JSNA) and Joint Local Health and Wellbeing Strategies (JLHWS) - HWBs consult widely and involve many different partners and communities in the development of their JSNA and their JLHWS to ensure that they understand the health and wellbeing challenges for their population, agree shared priorities and have a clear strategy for all partners to contribute to strategy. 
• Integrated Care Partnerships (ICPs) are intended to be inclusive and collaborative partnerships, led by ICBs and local authorities, to identify the strategic priorities for improving population health outcomes, joining up health and care and addressing health inequalities.
• Adult social care has adopted the ‘Think Local Act  Personal  approach, using ‘I’ statements and ‘We’ statements in ensuring that their priorities are centred on the needs and concerns of people who draw on care and support.   
• Despite the challenges, many health and care partners are already making good progress on digital shared care records and the roll out of social care records across registered providers.

Whatever the policy and regulatory frameworks and support mechanisms, they need to include the following components in order to promote an inclusive approach:

• Co-production – we note that the question does not seek information on the active involvement of people with lived experience of health and care services. It is essential that we involve them in the development of policy, regulation and support mechanisms.
• Provide time and space – engaging all partners takes time.  It is important to have clear timescales for reviewing existing frameworks and developing new ones and this must include time to hear from and work with all partners.
• Demonstrate that you have listened – adopt a ‘you said, we did’ approach to demonstrate to partners that their views have made a difference to policies and regulatory frameworks.
• Honesty and openness – be clear with partners what is in and out of scope to manage their expectations of what can be changed.

National targets and accountability

Question 5: What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system level decision-making?

LGA response

We recognise that the Government and its agencies lead the policy agenda for ICSs and as such, it is appropriate that they set a small number of high level and strategic targets. These should be focused on outcomes rather than process or activity. For example, setting broad targets for addressing health inequalities, to improve health and wellbeing outcomes, to improve access to health, care and wellbeing services and support.

ICSs are diverse in terms of their size, demography, health challenges, configuration of services and as such, they require the flexibility and freedom to identify their own targets for improving population health outcomes. It is equally important to recognise the diversity within ICS footprints, especially in the larger ICSs. ICSs will need to recognise and facilitate place-based leaders to identify their own priorities and set their own strategies for improving population health outcomes.

In recognition of  the diversity of ICSs, the LGA considers that variation in what ICSs agree as their priorities and how they go about addressing them is to be welcomed as it demonstrates that ICSs are evidence-based in their approach and responsive to local population health needs. 

Quality and safety need to be at the heart of ICS priorities. We would go further to say that they need to be at the heart of the priorities for all commissioners and providers of health and care services. In order to underscore this priority, all national guidance and strategies need to reflect that safety and quality is central to the transformation agenda.

The focus of the Review is on the relationship between ICSs, national Government, and its arms-length agencies, but we urge the Review to also consider the relationship between ICSs and existing place-based partnerships for integration, improving health and wellbeing outcomes and addressing health inequalities. Furthermore, the LGA contends that if the relationship between ICSs and places is not considered as a basic building block of accountability by the Review, this oversight risks destabilising or stifling good practice and innovation.

Question 6: What mechanisms outside of national targets, for example peer support, peer review, shared learning, or the publication of data at a local level, could be used to support performance improvement? Please provide any examples of existing successful or unsuccessful mechanisms.

LGA response

We strongly support a peer-led approach.  A summary of the key components of this approach is set out in response to Question 2 above. We also consider the following approaches effective in improving performance:

• Informal peer learning networks – the LGA, the NHS Confederation and other national organisations support national and regional networks which provide a ‘safe space’ for local government, ICS and professional leaders to exchange information, concerns, good practice and seek support from their peers. 
• We strongly support exchange of good practice so that all places and systems can learn from the best. Through our Leading Healthier Places and Leading Integration Peer Support Programmes, the latter co-produced with NHS Confederation and NHS Providers, the LGA supports performance improvement through webinars and a library of good practice case studies. We also provide peer reviews, development sessions, best practice workshops and mentoring opportunities. 
• Many HWBs have developed their own progress dashboards - based on the local priorities of the JLHWS.
• Peer to peer benchmarking – the LGA has developed a benchmarking tool – LG Inform – for councils, which brings a range of key performance, contextual and finance benchmarks together in an online tool. Users can view data from over 6,600 individual items, make comparisons between their authority and other councils or groups of councils. Registered users can tailor LG Inform outputs to suit their own needs by constructing their own reports and by bringing several data items together. Importantly, the data is maintained by the LGA and updated quickly after being published at its source.

Data and transparency

Question 7: What examples are there, at a neighbourhood, place or system level, of innovative uses of data or digital services to improve outcomes for populations, improve quality, safety, transparency, or experience of services for people, or to increase productivity and efficiency?

LGA response

There are several general principles of data and digital services that we recommend are applied at all levels:

• all partners need to have access to digital and data systems – including local authorities and the community and voluntary sector
• as far as possible, aim for a single data set, accessed and used by all, so that all partners have a single version of the truth
• maximise the use of existing data sets rather than creating new data collection and reporting burdens
• be clear about the purpose of data reporting and collection – what problem are you aiming to solve by collecting this data?
• be clear about the benefits and costs of collecting data, collating it at system, regional and national level.

The Social Care Digital Innovation Programme (SCDIP) and Social Care Digital Innovation Accelerator (SCDIA) projects provide a number of examples of broad digital interventions improving outcomes and productivity.  

A number of examples of local and regional innovative use of data are detailed below:

• Use of PAMMS (Provider Assessment & Market Management Solutions)
• Connecting councils and providers to improve care services
• East of England
• West Midlands ADASS – The Bridge
• Bristol City Council implements change with Adult Social Care Analytics from intelligent-i
• Cheshire and Merseyside Combined Intelligence for Population Health Action (CIPHA) programme.

North West ADASS Markets Quality and Insight System (MQIS) is an online platform that enables local authorities to aggregate, analyse and visualise data, primarily about the region’s expenditure for care services. Each of the 23 local authorities in the North West submits spend and placement data, but the system also incorporates supplementary data sources to effectively inform commissioning strategy, market oversight, risk profiling, quality improvement and provider engagement.  

MQIS offers highly visual and interactive insights, with the main dashboards covering market share, purchasing power, out of area placements, and CQC quality. These datasets are integrated, offering a 360 view of the Adult Social Care Marketplace in a tool that is functional and easy to use.  

Nationally, LG Inform provides councils with a number of reports to support councils to access, utilise and interpret the data and intelligence that can help to inform their understanding of their local, regional and national social care sector and support effective decision making 

Question 8: How could the collection of data from ICSs, including ICBs and partner organizations, such as trusts, be streamlined and what collections and standards should be set nationally?

LGA response

Data sharing needs to underpin integrated health and care. The approach needs to work for all stakeholders, including citizens, and must benefit all partners. Currently many local authorities get very little data insight at the local authority geography of interactions between their local populations and hospitals. This leaves a significant gap in the intelligence needed to design effective local integrated services and needs to be urgently addressed.

Partners needs to maximise timely insight and intelligence whilst minimising unnecessary burden. We already capture a vast amount of detailed data, but this is not utilised in a way that supports the timely, person-focused, place-based intelligence needed. Whilst there is increasing focus on the aggregated data required by central government, we need to review the timelines and accessibility of shared data at an operational level. Where information is captured in relation to individuals, characteristics can be linked dynamically to both organisations and locations to get valuable intelligence - for example, information relating to hospital admissions could be mapped back to local health or council geographies to help understand any patterns affecting needs and care pathways.

A Minimum Operational Data Set for a Digital Social Care Record (MODS) and Minimum Reporting Data Set for a Digital Social Care Record (MRDS) is being developed by NHSTD in partnership with the sector to enable data collection from care providers. This needs to support not only DHSC and ICSs, but councils as part of their commissioning responsibilities within an ICS. There are mutual benefits at all levels and plans to continue with some degree of national overview and intelligence about the care market. Individual councils need the ability to continue to manage relationships with their local providers. Any future approach for utilising health and care data must be driven from the local needs of councils and care providers, with the flexibility to ‘focus in’ and ‘scale up’ when appropriate.

A big proportion of social care providers in any ICS place have 10 employees or less. It is unrealistic to bring all of these up to the standard of larger organisations in terms of the type and frequency of data that can be provided. There needs to be dedicated investment as there is no real incentive for largely private businesses to invest and see themselves as players in a wider system when they are generally operating at high levels of occupancy or use and cannot expand because of workforce shortages.

Question 9: What standards and support should be provided by national bodies to support effective data use and digital services?

LGA response

The LGA has worked closely with Government and NHS England to ensure that the needs of adult social care are considered in joining up digital systems. Local authorities are likely to experience substantial and costly changes to social care data systems and in other technology developments such as telecare. There are particular challenges for developing shared data systems in areas where ICS and local authority do not share boundaries. 

Digitising social care records is a key step towards achieving an integrated shared care record (ShCR) across health and social care. Outcomes for people are greatly improved if we all have the right information at the right time and can share one version of the truth. The increased support for social care providers to move towards having a digitised care record has been essential and a good example of where the central support and investment from Government can have positive impacts.

There are significant gaps in our day to day understanding across data systems, particularly in adult social care, where care provision sits mainly outside of local authorities and is dispersed across nearly 18,000 registered care providers. The pandemic further highlighted this issue and exposed our limited ability to respond to emerging risks within the entire sector with timely, reliable data. As an interim response, social care providers voluntarily submitted data to the Capacity Tracker tool, which continues to be relied on as a source of capacity data whilst we roll out a longer-term digital solution to obtain data from providers to support system capacity and flow.  Availability of good-quality and timely data from social care providers that does not require manual input is essential to improve services for users, support efficient commissioning and systems assurance, and to manage national, regional, and local risks.

The achievement of national targets (as set out in the White Paper: People at the Heart of Care) for shared care records and further digitisation of the social care sector is supported by a small amount of national infrastructure within the DHSC and NHS England but the resources available do not recognise the scale and complexity of the task, where the majority of providers are small and medium-sized businesses and have no digital infrastructure of their own.

Digital literacy and confidence levels are also low (27 per cent reporting ‘pre-novice’ levels in the 2022 IPSOS MORI survey) and parity of esteem with the NHS needs to be achieved in establishing competence and digital, data and technology roles within social care. There is currently no national programme to do so and no national workforce strategy to contextualise this need within an overall skills gap analysis.

NHS Transformation Directorate (NHSX as was) worked with social care leaders to establish a national programme scaling up monitoring devices that will support the use of data alongside AI to provide insight through predictive modelling that will help ICSs to manage falls and other untoward events for people in care homes. This type of ‘anticipatory’ approach, using local data in local settings, particularly people’s own homes, needs further investment and national coordination to avoid its use being subject to pilots and pockets of good practice on time-limited funding streams.   

System oversight

Question 10: What are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?

LGA response

The Review will need to be clear what they mean by ‘variation.’ There is already huge variation between ICS in terms of their size, demography, health challenges, configuration of services and track record in collaborative working. In recognition of this, the LGA considers that variation in what ICSs agree as their priorities and how they go about addressing them is to be welcome, as it demonstrates that ICSs are evidence based in their approach and responsive to local population health needs. Given that ICSs should be, at the very least, the sum of their parts one of the most crucial things to assess is the degree to which the ICB is acting as an enabler, meaningfully engaging with partners, and adopting the principles set out in the Confed and LGA ‘top tips’.

A rigid national template for how all ICSs should seek to improve population health and health inequalities simply would not be achievable or helpful. However, we should aim to minimise the variation in terms of access to services, support and treatment. But even in this respect, there will need to be local variation in the way in which services are accessed and delivered, for example, there are inevitably differences in access to services and support between rural and urban areas.

In addition, all ICSs have different starting points for the health challenges of their populations and the progress they have made in joining up care and support for people. There will, inevitably, be variation between ICSs but all should aspire to make demonstrable improvements in improving services, addressing health inequalities and improving population health outcomes. 

Finally, there is already huge variation in the NHS in terms of access to services, service quality and outcomes. ICSs need to be clear about the reasons for this variation and where it is unwarranted to learn from other ICSs that have smoothed variation.  ICSs will need to be transparent and accountable to local people and to partners, as well as accountable to NHSE and upwards to Parliament for broad national priorities.

The role of system oversight and/or ICS assurance should not solely be about identifying areas of poor performance. It also has a role in identifying and promoting best/good practice as part of wider efforts for continual learning and improvement. Equally, oversight and assurance is not just a national function. Local authority health oversight and scrutiny makes an important contribution to improving local performance and needs to be recognises as a valued and important oversight function.

There needs to be appropriate read-across between ICS and ASC assurance. For the latter, the emerging framework is organised around four key themes: how local authorities work with people; how local authorities provide support; how local authorities ensure safety; and leadership. Careful consideration needs to be given to how performance in these four themes may impact on ICS performance (and vice-versa). For example, the ‘Leadership’ theme (with expected CQC Quality Statements on ‘governance, management and sustainability’ and ‘learning, improvement and innovation’) is likely to have a strong focus on culture and strategic planning, evidence for which will likely come in part from health partners, the HWB, and the ICP. The interaction between ICS and ASC assurance here needs to avoid unhelpful duplication of effort, particularly given capacity pressures on health and social care.

Question 11: What type of support, regulation and intervention would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues?

LGA Response

The LGA strongly recommends a peer-led approach to support and intervention, in which all ICSs and their partners within them adopt a commitment to continuous improvement.  Questions 2 and 6 set out in broad terms the LGA’s peer-led approach. 

Support, regulation and intervention for ICSs needs to align appropriately with the similar processes that will be in play for ASC assurance. For example, if ASC assurance ends up with a council entering ‘enhanced monitoring and support’ (non-statutory intervention) and/or ‘statutory intervention’, would that automatically trigger a flag for ICS assurance (and vice versa)? If so, what does (or should) that mean for the timetable of assurance between ICS and ASC?

As is being debated and discovered in ASC assurance, regulation and intervention needs to find a careful balance between the creation of a clear national framework and one that is also able to take account of local circumstances and particular local issues. A similar balance will presumably need to underpin regulation and intervention for ICSs.

Should an ICS enter some form of intervention, there will need to be clear processes for both entering and exiting that state. In respect of entering intervention, consideration will need to be given to whether other evidence/developments (i.e., beyond CQC assessment) would trigger intervention and support. In terms of exiting intervention, consideration will also need to be given to the evidence required to demonstrate that the ICS is capable of leading its own improvement.

Accountability through locally elected politicians is a crucial foundation of local government and has additional importance in the realm of partnership working. The role of senior councillors in ICS assurance needs to be thought through given the possible tension between a commitment to localism and a desire for stronger national levers of accountability.

More generally, the twin processes of ICS and ASC assurance (taking in all aspects of assessment, support, monitoring, review, escalation and intervention) will likely create the need for experts skilled and experienced in local government, health and integration. Realistically, this pool is probably limited so there needs to be an honest conversation about system-wide capacity.

One final point regarding support, regulation and intervention, there needs to be a national process for reviewing and revising ICS footprints in the small proportion of areas where the footprint has been identified by the NHS and local authorities within the ICS as a major hindrance to effective joined up working. We are not proposing a wholesale review of ICSs and in the majority of areas, ICS boundaries do not need to be reviewed. We are keen to work with NHSE to develop a process which is clear, proportionate and only used as a last resort.