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NHS England has published a new document setting out proposals for legislative reform and the direction for integrated care systems (ICSs) that aim to cover England by April 2022.

Entitled ‘Integrating care: Next steps to building strong and effective integrated care systems across England’, the document opens up a discussion with the NHS and its partners about how ICSs could be embedded in legislation and guidance. The UK Government would then make decisions on these proposed legislations.

It builds on the route map set out in the NHS Long Term Plan for health and care joined up locally around people’s needs. The push is for greater collaboration across health and social care, and commissioning, to holistically meet people’s needs.

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An integrated care system (ICS) is a new, closer form of collaboration in which the NHS and local authorities take on greater responsibility for managing resources and performance. Through deepening the relationship between the NHS and local authorities, ICSs aim to improve the health of all residents, preventing illness, tackling variation in care, and delivering seamless services.

ICSs aim to cover every part of England by April 2022.

Now, NHS England’s latest document details how systems and their constituent organisations will accelerate collaborative ways of working in future, considering the key components of an effective ICS and reflecting on learnings over the past two years, including challenges presented by the COVID-19 pandemic.

The document also describes options for giving ICSs a firmer footing in legislation likely to take affect from April 2022. These proposals sit alongside other recommendations aimed at removing legislative barriers to integration across health bodies and with social care.

To ensure ICSs can effectively cover England, the NHS says this will involve stronger partnerships in local places between NHS organisations, local government and others. It will also mean that provider organisations will need to step forward in formal collaborative arrangements to enable them to operate at scale.

Additionally, the document says that strategic commissioning arrangements will need to be developed that focus on population health outcomes as well as the use of digital and data to drive system working, connect health and care providers, improve outcomes and put the citizen at the heart of their own care.

To ensure ICSs work, NHS England has laid out a series of practical changes that will need to take place by April 2022 to enable more integrated care.

Provider collaboratives

To tackle health challenges in a local population, the document says that providers will need to join up services across systems, which will happen in two main ways:

  1. within places (for example, between primary, community, local acute, and social care)
  2. between places at scale where similar types of provider organisation share common goals such as reducing unwarranted variation, transforming services, providing mutual aid through a formal provider collaborative arrangement (for example, through an alliance or a mental health provider collaborative).

“All NHS provider trusts will be expected to be part of a provider collaborative,” NHS England states. “These will vary in scale and scope, but all providers must be able to take on responsibility for acting in the interests of the population served by their respective system(s) by entering into one or more formal collaboratives to work with their partners on specific functions.”

The document says this greater coordination between providers can support higher quality and more sustainable services; reduction of unwarranted variation in clinical practice and outcomes; reduction of health inequalities; better workforce planning; and more effective use of resources, including clinical support and corporate services.

Place-based partnerships

NHS England says that common characteristics of the most successful place-based partnerships are the full involvement of all partners who contribute to the place’s health and care; an important role for local councils (often through joint appointments or shared budgets); a leading role for clinical primary care leaders through primary care networks; and a clear, strategic relationship with health and wellbeing boards.

Importantly, the document highlights, the place leader, on behalf of the NHS, should work with partners – like local authorities and outsourced community equipment service (CES) providers – in an inclusive, transparent and collaborative way.

Place leaders’ main roles include simplifying, modernising and joining up health and social care, which could be done through the provision of assistive technology. Furthermore, NHS England states, these leaders should coordinate the local contribution to health, social and economic development to prevent future risks to ill-health within different population groups.

“Systems should ensure that each place has appropriate resources, autonomy and decision-making capabilities to discharge these roles effectively, within a clear but flexible accountability framework that enables collaboration around funding and financial accountability, commissioning and risk management. This could include places taking on delegated budgets,” NHS England continues.

Financial framework

One big theme in the new document is the idea of pooled budgets between health and social care.

In order to deliver more integrated, person-centred and preventative care, the document says that the NHS will increasingly organise the finances of the NHS at ICS level and put allocative decisions in the hands of local leaders. It says that ICSs want to be key bodies for financial accountability and that financial government arrangements must reflect this.

NHS England says that this means creating a ‘single pot’, which brings together current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally-held transformation funding that is allocated to systems.

By doing this, ICS leaders will be expected to use new freedoms to delegate significant budgets to ‘place’ level i.e. more locally. The document adds that creating a single pot will make it easier for the NHS to form joint budgets with the local authority.

Commissioning changes

NHS England says that it has been repeatedly told by local leaders that the commissioning functions currently carried out by Clinical Commissioning Groups (CCGs) need to become more strategic, with a clearer focus on population-level health outcomes.

This means current commissioning functions will need to evolve, which will change in three significant ways in the future, the document advises:

  1. Ensuring a single, system-wide approach to undertake strategic commissioning. This will discharge core ICS functions, which include:
    – assessing population health needs and planning and modelling demographic, service use and workforce changes over time;
    – planning and prioritising how to address those needs, improving all residents’ health and tackling inequalities; and
    – ensuring that these priorities are funded to provide good value and health outcomes.
  2. Provider organisations and others become a principal engine of transformation and should agree the future service model and structure of provision jointly through ICS governance.
  3. The greater focus on population health and outcomes in contracts and the collective system ownership of the financial envelope is a chance to apply capacity and skills in transactional commissioning and contracting with a new focus. Analytical skills within systems should be applied to better understand how best to use resources to improving outcomes, rather than managing contract performance between organisations.

Legislative proposals

Previously recommended by NHS England, key legislative proposals for ICSs include: rebalancing the focus on competition between NHS organisations by reducing the CMA’s role in the NHS and abolishing Monitor’s role and functions in relation to enforcing competition; the ability to establish decision-making joint committees of commissioners and NHS providers and between NHS providers; enabling collaborative commissioning between NHS bodies; and merging NHS England and NHS Improvement (NHSEI).

The document says that these legislative proposals still stand but the NHS and its partners still wanted more statutory clarity surrounding ICSs.

NHS England says it believes there are two possible options for enshrining ICSs in legislation, without triggering a distracting top-down reorganisation:

  1. a statutory committee model with an Accountable Officer that binds together current statutory organisations.
  2. a statutory corporate NHS body model that additionally brings CCG statutory functions into the ICS.
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