Eight key questions to ask when building an…

The expectations of health systems to improve population health, deliver high-quality care and integrate services - and all while reducing costs - have never been higher. Integrated Care Systems (ICSs) must contribute to these priorities, whilst also being a policy priority in themselves. However, designing and implementing ICSs is a complex business. Local areas must consider a wide array of interdependent change programmes, all alongside ‘business as usual’ concerns and pressures. That means thinking through exactly what changes are needed, when, and how they relate to each other, can be an imposing challenge.

The national policy picture is helpful here – but only up to a point. For example, NHS England’s Maturity Matrix for integrated care systems makes clear what local areas should be achieving, but not how they should set themselves up to achieve it.

So, here’s an alternative approach. Eight questions – based on our experience of working with emerging ICSs – to ask that will highlight what you need to make progress. Answer them all convincingly and you’re well on the way to building a locally-tailored ICS. But beware, some are tougher than they first appear…

Who are you? And who are you serving? Starting as Sustainability and Transformation Partnerships (STPs), most emerging ICSs shouldn’t have a problem articulating who’s working together and on behalf of which population. Not all members will be obvious, however. In particular, STPs including specialist Trusts will need to articulate what role they see them playing in their ICS, and what that means for both the Trust and neighbouring ICS areas.
Why do you want an integrated care system? 'Because the long-term plan requires it' is an insufficient answer. Securing the buy-in to change that partners will require – especially Local Authority partners – will necessitate a locally-specific case for an ICS-specific change (as opposed to more general services improvements). Without this specific case for change in place from the outset, individuals and organisations will be tempted to row back once conversations turn to the specifics of service design, organisational form or finance (see questions 4-6 below).
Is the leadership in place to drive change? Are they up to the task? Are the most senior leaders meeting regularly to discuss whole system issues, and are they working together effectively to resolve them? Does the group have the support it needs to really drive change – including an effective programme management office and secretariat as well as change management capacity? Is the group considering the right issues, at the right time, and with the right information to make the most effective decisions about the future of the system? Without effective governance and support, STP/ICS decision-making arrangements will soon either be bypassed or fall into obsolescence, and any momentum for change will go with them. Dedicated ICS programme teams don’t need to be large, but they do need to have the credibility, and the planning and governance capability, to ensure the Board can work effectively to drive change across the system.
What will care look like in your ICS? How will it differ from the current position? The requirements of STPs – not to mention many years of earlier work on integration – mean most systems have now articulated specific changes to care that they want to implement. The challenge now is to bring them together into a coherent model of care – specified in as much detail as possible - which the ICS will be charged with enabling and delivering. Answering this question should explicitly build on, rather than duplicate or contradict, the large amount of relevant thinking (and clinical engagement) that all systems will already have done in this area.
What will the ‘system’ look like? Who will do what and when? Who will hold them to account and how? Although NHS England has made clear there will be no national model for ICSs, there is now a national view on key building blocks. But if neighbourhoods, places and systems are now fixed points, there’s a lot to do to articulate how they will work together in a way that delivers the new, integrated model of care in a way that meets each area’s needs (as described at question 4 above). Which services will neighbourhoods and places provide, and how will they be supported to provide them effectively? How do places relate to local authority and acute services? It’s a lucky system where all these boundaries align neatly. And how will the system provide an effective and coherent framework and hold neighbourhoods and places to account, without stifling innovation or adaptability to local needs?
How will you manage the money? Some leading ICS areas have made financial reform a centrepiece of their work. Others have aimed to avoid it. But it’s clear an effective ICS plan needs to include articulation of how the money stacks up and which financial incentives and mechanisms will explicitly support the new ways of working.
What’s your offer to NHSE/I, and what do you want in return? With the direction of travel towards regulation of systems rather than organisations, NHSE/I have a lot to gain from effective ICSs. In exchange for assurance that areas will become essentially self-regulating (for which the answers to the two questions above should provide most of the evidence), ICSs can make a pitch for the freedoms, flexibilities and resources they need to implement their proposed changes successfully. Which leaves one final question.
How will you put your plans into action? How will the large number of changes be managed in a way that keeps them co-ordinated while maintaining focus on the benefits to achieve (see questions 2 and 4 above)? And where will the resources come from to implement them? Some ICS leaders have drawn on central or regional funding or other resources (such as seconded staff). Others have ensured contributions from across their members. This latter route will be most realistic for most areas.

Answers are emerging in some of these areas, either through national guidance or practice across systems (including from ICS leaders). But a lot of questions remain. This means either freedom for areas to design ICSs that truly meet local needs, or a concerning lack of direction about how a national policy should be implemented – depending on your perspective.

To justify the emphasis placed on them, ICSs must define and deliver a new model that supports care teams to be most effective at improving outcomes for local people. These questions provide a guide for systems to think through their own progress towards this, and therefore where future efforts should be focussed in order to realise this most challenging of goals.