Health and wellbeing is important to us all, and we all want to ensure patients receive high quality and safe care. Yet many of us face a realisation that neither we, nor our individual organisations, can always achieve the outcomes we should expect to see. Growing demand and increasing funding challenges have created a gap between available resources and patient need, which efficiency alone will not close.
We see also that wider determinants of health have significant impact on health outcomes, with factors such as education, employment and income contributing to 40% of health outcomes. These are closely followed by health behaviours (30%), such as smoking and alcohol, with the built environment contributing to 10%.
If we concentrate solely on access and quality of clinical care, we will be contributing to only 20% of outcomes, so understanding and addressing the impact of these wider determinants on individuals underpins our ability to improve longevity and quality of life.
As clinical leaders, we know that to make any progress we need to see cross-organisational prioritisation with multi-year alignment of resources, so we can achieve better outcomes and better value for money.
Integrated care systems
Integrated care systems (ICSs) provide us with that opportunity. Forty-two ICSs were formed on 1 July 2022 under the Health and Care Act 2022, many having existed in shadow form for a number of years.
They do not replace individual organisations, but instead exist to bring together all public services and partners across a geographic area, with four strategic purposes in mind; improving population health and healthcare, tackling unequal outcomes and access, enhancing productivity and value for money, and supporting broader social and economic development.
All ICSs have a generic framework, while retaining the ability to implement that framework in the most appropriate way for the population they serve (see King's Fund graphic below).
Integrated care boards
Integrated care boards (ICBs) replace the 106 clinical commissioning groups (CCGs) as the statutory body responsible for planning and delivery of NHS health and care services. They receive the ICS's nationally allocated amount' for revenue and capital, removing the purchaser/provider split. ICBs decide how their national allocation will be spent across the system, with partners working collaboratively to deliver agreed priorities.
ICBs will establish governance arrangements to support collective accountability between partner organisations for whole system delivery and performance, underpinned by the statutory accountabilities of individual organisations. This distributed network of leaders across the system lets partners hold themselves and each other collectively to account, rather than relying on performance management.
Joint working on workforce development and infrastructure, such as estates and digital capabilities, will be essential. While ICSs have been expected to break even financially, effective and sustainable transformation to shape services to meet the challenges of the future will require investment.
Copyright: The King's Fund (Creative Commons Attribution-NonCommercial-NoDerivs 4.0 licence.) Source: www.kingsfund.org.uk/audio-video/integrated-care-systems-health-and-care-act
Photo credit: The King's Fund
NHS England also plans to delegate the commissioning of specialised services to ICBs from April 2023. Once suitability and readiness of ICSs for delegation is determined, services will be able to be commissioned by individual ICSs, or they might choose to collaborate and work at greater scales with other ICSs or whole regions. Commissioning of highly specialised services (complex, low patient and provider numbers), accounting for approximately 20% of specialised spend, will be retained nationally.
Integrated care partnerships (ICPs) bring together health, local government and all public service and partner organisations across the system, such as the voluntary, community, faith and social enterprise sectors, policing, education and others. ICSs set the strategic intent of the partnership, putting the population's needs ahead of any sector or organisation-specific areas of focus.
Provider collaboratives enable primary, community, mental health and acute providers to work effectively at scale. With access to joined-up data to create actionable insight, clinical leaders should agree how to optimise models of care and align cross-organisational resources to pathways that address the needs of patients, as well as the teams of professionals supporting them and each other. Systems are starting to see the benefits in elective recovery, urgent and emergency pathways and services for children and young people.
Clinical leaders should agree how to optimise models of care and align cross-organisational resources to pathways that address the needs of patients, as well as the teams of professionals supporting them.
Levels of care - the importance of place/neighbourhood
Trends or needs at a wider 'system' level can be very different than at smaller 'place' or 'neighbourhood' levels (see King's Fund graphic above). For example, life expectancy in the Frimley ICS overall has increased and is higher than the England figure for both men and women. However, in several neighbourhoods it remains materially lower than the national benchmark. There is a 12-year difference in life expectancy across the system, with a one-year loss in life expectancy for every mile travelled.
Place and neighbourhood locations give us a real opportunity for evidence-based decision-making to tailor delivery of our system-wide priorities, to make sure we best meet the needs of our communities. We can understand with precision, and at an individual level, the data and information that enables mapping of interventions and deployment of services.
Primary care networks (PCNs) allow for new approaches to plan, deliver and transform services, and for determining whether delivery for quality and outcome is best at pan-system or at place/neighbourhood level.
Priorities are based on community insights and co-design with residents. Multi-professional integrated working, including non-healthcare professionals, supports people to help prevent ill health with conditions such as diabetes, obesity and mental illness. Closer collaboration and partnership working between health, local government and the voluntary sector facilitates a more holistic, joined-up approach to managing the health and wellbeing of all residents at place level.
The ambition of system working is to support populations to remain as healthy, active and independent as they can be - to know who to contact if they need help and only have to tell their story once, to increase their ability and confidence to take responsibility for their own health, care and wellbeing, and to be confident that if they do need help, it is easily accessible and provided in the best possible way.
ICSs will publish an initial interim strategy by December 2022, which will align and influence joint system partner five-year forward plans from April 2023.
The views expressed in this article are those of the author and do not necessarily reflect those of the MDU.
Dr Priya Singh
Dr Priya Singh is chair of NHS Frimley ICB. She has a background in general practice and legal medicine and also chairs the National Council for Voluntary Organisations (NCVO), is deputy chair at Guy's and St Thomas' NHS Foundation Trust and director of the Society for Assistance of Medical Families (SAMF), a mutual benevolent fund with charitable status.
See more by Dr Priya Singh