The BHTA guide to understanding Integrated Care Systems
As the Department of Health & Social Care (DHSC) introduces new reforms in its efforts to better integrate the health and social care system in England, there will be increasing use of a range of unfamiliar terminology: Integrated Care Systems (ICSs), Integrated Care Boards (ICBs), and Integrated Care Partnerships (ICPs). To help provide clarity, the British Healthcare Trades Association (BHTA) has produced this simple guide, highlighting and defining some key terms.
Integrated Care System (ICS) – Definitions
Integrated Care System (ICS): Broad, regional, health & social care delivery area/operating unit that brings together providers/commissioners of NHS services, Local Authorities, and other stakeholders to collectively plan and deliver health & care in an integrated fashion, joining up hospital and community-based services, physical and mental health, and health and social care; all parts of England are now covered by one of 42 ICSs.
Integrated Care Board (ICB): Legally constituted leadership & governing body for an ICS.
Integrated Care Partnership (ICP): Planning body of an ICS, operating at the “Place” level (see ICSs – Mission & Components below).
Integrated Care System (ICS) – Background
As part of the Health & Care Bill 2021 – and in line with the January 2019 NHS Long-Term Plan – the government is reforming the way health & care services are planned, delivered, and funded by shifting to Integrated Care Systems (ICSs). ICSs have grown out of organic efforts by some NHS Trusts and Clinical Commissioning Groups to work more collaboratively over the last two decades in Sustainability and Transformation Partnerships (STPs), and some have already begun operating, voluntarily, as ICSs.
The government is now placing ICSs on a statutory footing, meaning they will have basis in legislation, with formal powers and accountabilities. As part of this process, DHSC, NHS England, and NHS England Improvement are beginning to publish guidelines and policies setting out how ICSs and their constituent/related parts will work.
ICSs – their evolution, structure, and future operations – are a very complex topic, and forward-looking analysis of their development and operation is made more difficult by the fact that their ways of working and governance structures are in constant flux. By far the best all-in-one-place, plain-English summary of ICSs is a May 2021 “explainer” published by The King’s Fund – Integrated Care Systems Explained – Making Sense of Systems, Places and Neighbourhoods – although even its analysis is being overtaken by events as ICSs (and the government’s guidance for them) continue rapidly to evolve.
Integrated Care System (ICS) – Mission and Components
Integrated Care System (ICS): A partnership between the organisations (NHS, Local Authorities, social & care bodies, and other stakeholders) that meet health and care needs across an area, which allows for planning and coordination in ways that improve population health and reduce inequalities between different groups.
The core purpose of an ICS is to:
- Improve outcomes in population health & healthcare
- Tackle inequalities in outcomes, experience, and access
- Enhance productivity and value for money
- Help the NHS support broader social & economic development
ICSs operate, broadly speaking, at three levels:
- System (populations c. 1-3 million people), in which a whole area’s health & care partners in different sectors come together to set strategic direction and develop economies of scale;
- Place (populations c. 250,000-500,000 people), served by a set of health & care providers in a town or district, connecting primary care networks to broader services including those provided by local councils, community hospitals, or voluntary organisations; the definitions/boundaries at this level may match local council boundaries or natural geographies within which services are delivered;
- Neighbourhood (populations c. 30,000 – 50,000 people), served by groups of GP practices working with NHS community services, social care, and other providers to deliver coordinated and proactive services, including through primary care networks;
Integrated Care Board (ICB): Responsible for the commissioning of healthcare services in an ICS area, bringing together the NHS, Local Authorities, and other stakeholders to improve population health and care. If the Health & Care Bill 2021 is passed into law:
- ICBs will be established from April 2022 as a new type of statutory NHS body;
- Clinical commissioning groups (CCGs) will be dis-established; and
- ICBs will take on the same statutory functions as those currently held by CCGs (in addition to new functions and responsibilities set out in legislation and policy)
Integrated Care Partnership (ICP): A broad alliance of organisations and representatives concerned with improving the care, health, and wellbeing of the population, jointly convened by Local Authorities (LAs) and the NHS. The ICP will:
- Provide a forum for NHS and LA leaders to come together, as equal partners, with stakeholders from across the ICS and the community;
- Generate an integrated care strategy to improve health and care outcomes/experiences for the ICS’ population, for which all partners will be accountable, and which will be delivered – largely – by the Neighbourhood-level providers within an ICS.
For a brief (7-page) overview of the different levels of management that make up an ICS – including their core functions, the rationale behind them, and how they will work together – please see the NHS’ June 2019 guidance document Designing Integrated Care Systems (ICSs) in England. For more detail on ICSs, ICBs, and ICPs, please see the NHS’ June 2021 guidance document Integrated Care Systems: Design Framework.
Summary of Integrated Care Partnership (ICP) Engagement Document: Integrated Care System (ICS) Implementation (Government guidance, published 15-Sep-21)
The top-line takeaway of this document is that – howsoever it purports to be guidance – it operates under DHSC’s clear and repeated caveats that the government does not foresee much detailed guidance at all with regard to ICPs or their operation, so as to preserve maximum flexibility at local levels, viz:
- “we do not intend to produce prescriptive guidance for ICPs, [which] will be a dynamic element within every system, building on the assets that already exist in the community and wider system, and adapting as populations and priorities change, and relationships develop over time”
- “DHSC has chosen to minimise the level of prescription around ICPs in the primary legislation [since] experience has shown us that systems are most effective when there is a national framework that provides guidance and ensures consistency, while allowing for maximum local flexibility in how they operate and design themselves to meet local needs over time”
That said, DHSC sets out several expectations for ICPs.
- Be required to be established in every [ICS];
- Have a minimum membership required in law (the ICB and LAs); and
- Will be tasked with producing an integrated care strategy for their [ICS].
ICPs’ central role is in the planning and improvement of health and care. They should support place-based partnerships and coalitions with community partners which are well-situated to act on the wider determinants of health in local areas.
ICPs will be required to develop an integrated care strategy to address the broad health and social care needs of the population within the ICP’s area, including determinants of health such as employment, environment, and housing issues.
ICPs are expected to highlight where coordination is needed on health and care issues and challenge partners to deliver the action required.
The greatest detail in the guidance is around examples and suggestions – not requirements or prescriptions – as to how DHSC expects ICPs to “add value” in the areas that form DHSC’s five key expectations of ICPs:
- ICPs are a core part of ICSs, driving their direction and priorities
- ICPs will be rooted in the needs of people, communities and places
- ICPs create a space to develop and oversee population health strategies to improve health outcomes and experiences
- ICPs will support integrated approaches and subsidiarity [the principle of subsidiarity is the idea that decisions should be made as close as possible to local communities]
- ICPs should take an open and inclusive approach to strategy development and leadership, involving communities and partners to utilise local data and insights
DHSC expects that all ICSs will have at least an interim ICP up and running when statutory ICBs commence as planned in April 2022, subject to the passage of the Health and Care Bill 2021 through Parliament.
In closing, DHSC “now ask all 42 integrated care systems to take the following five steps, [and for] NHS ICB Chairs Designate to ensure these steps are carried out in their system, in partnership with local government”:
- Recognise that it is for the NHS and LAs – as the statutory partners in each ICS – to start the process jointly of creating an ICP in preparation for legislation (September 2021)
- Reach agreement between NHS and local authority leaders as to how the ICP will be established and a secretariat resourced, at least during the 2021/22 transition year (October 2021)
- Ensure that the statutory ICP partners come together as required to oversee ICP set up, including engagement with stakeholders (November 2021)
- Appoint an ICP chair designate, taking account of national guidance on functions and ensuring there is a transparent and jointly supported decision-making process (February 2022)
- Determine key questions to be resolved for that particular ICS (April 2022)
The guidance closes with an FAQ document.