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NHS England has published a new document that sets out proposals for legislative reform within the NHS for more collaborative ways of working across health and social care.

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 integrated care systems (ICSs) could be embedded in legislation or guidance.

The new document builds on plans set out in the NHS Long Term Plan for health and care to be joined up locally around people’s needs. It looks at how greater collaboration across health and social care can help meet critical health and care challenges and break down silos.

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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.

In an ICS, NHS organisations, in conjunction with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.

From a clinical perspective, ICSs may reduce barriers between services and competition between providers, leading to improved patient care. From a local government perspective, ICSs have a key role to play in working with councils at ‘place’ level with commissioners making shared decisions with providers on how to use resources, design services and improve population health.

By April 2021, ICSs aim to cover the whole country.

Integration at ‘place’ level

NHS England states that one of its main ambitions is to ensure integrated care at ‘place’ level i.e. the local place in which people live.

At place level, NHS England aims to ensure that everyone is able to access: clear advice on staying well; a range of preventative services; simple, joined-up care and treatment when they need it; digital services (with non-digital alternatives) that put the individual at the heart of their own care; and proactive support to keep as well as possible.

The document says that this will be met through providers of different services – such as social care, primary care, housing and mental health services – working together with delegated budgets to join up services. NHS England notes this will allow links to be made between key services that will have a big, positive impact on people’s everyday health.

Proposed changes

Building on the theme of person-centred, integrated care, the document sets out a series of proposed practical changes that will need to be in place by April 2022 at the latest to ensure closer collaboration between systems and providers.

The document outlines that NHS England will work more closely with local government at place level to ensure local health and wellbeing outcomes are met by the NHS becoming a more effective partner in the planning, design and delivery of care.

Importantly, NHS England proposes that to ensure the collective leadership of each ICS has the best possible opportunity to invest in, and deliver, joined-up, more preventative care, finances should be organised at ICS level and allocative decisions should be put in the hands of local leaders. The organisation says that ICSs should be key bodies for financial accountability and financial governance arrangements will need to reflect this.

This means that a ‘single pot’ will be made available, bringing 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.

With the push to integration, the document says that more joint-up working will enable providers to shape the strategic health and care priorities for the populations they serve and determine how services are funded and delivered, and how different bodies involved in providing joined-up care work together.

Important commissioning changes

One of the most important parts of the document discusses changes to the commissioning process, making it more strategic and with a clearer focus population-level health outcomes.

The activities, capacity and resources for commissioning will change in three significant ways in the future, NHS England emphasises, which are as follows:

  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; and ensuring that these priorities are funded to provide good value and health outcomes.
  2. Service transformation and pathway redesign need to be done differently. Provider organisations and others, through partnerships at place and in provider collaboratives, 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.

Undoubtedly, though, one of the biggest proposed changes set out in the document is for current Clinical Commission Group (CCG) commissioning functions to be absorbed to become core ICS business. This would see ICSs take on the commissioning functions of CCGs, with the CCG governing body and GP membership model replaced by a board consisting of representatives from the system partners.

Under these proposed changes, NHS England says that ICSs’ primary duty would be to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations. It would have the flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers.

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