By Catherine Skilton, Partner Deloitte’s Public Sector Healthcare team


As the first half of the year draws to a close, we in the Deloitte healthcare practice have decided to take stock and reflect on some of the key challenges facing NHS organisations as they come together to form Integrated Care Systems (ICSs). We have asked senior colleagues from across the firm to highlight the burning questions they are being asked about most frequently – and more importantly, what advice they provide.

Their views and insights will form a series of blogs over the summer months on a wide range of topics impacting ICSs, from the future state of commissioning to how Primary Care Networks (PCNs) fit with existing GP Federation boundaries. Our intention in sharing these insights is to identify and provide some potential solutions to the key challenges that we see NHS organisations facing, especially as they look to respond to the expectations in the NHS Long Term Plan (LTP), particularly the need to form ICSs.

This first blog introduces the topics we will be covering in more depth over the next few months and gives a flavour of the key questions we will be responding to.

ICSs - Hot topics

Our healthcare strategy team will discuss what it takes to make decisions as a system. They will explore how some of our new, and soon-to-be, ICSs can prepare for and operationalise joined-up, placed-based, strategy development and decision-making. What we are seeing today is that within the current policy context, systems often split strategy-development from execution, with the success of the resulting structures heavily dependent on the delegated decision-making power and levels of trust among members. We will explore therefore how commissioners are evolving and defining their future role, and how they can transition away from transactional to more strategic activities.

Practitioners from our Board Advisory Practice will share their experience of setting up and constituting new, enabling governance structures. They will explore how these structures need to align with existing legislation, particularly in the context of organisation-based (rather than system-based) accountability and how they can help deliver NHS and Local Authority priorities.

The efficiency challenge is high on the list of priorities set out in the LTP. Collaborating at a system-level creates significant opportunity to reduce duplication and deliver efficiencies. Our Finance and Performance Team will therefore share the lessons they have learned from working with organisations to help them to decide what activities they should be undertaking more collaboratively and at what level (whether, system, locality, sub-locality, or neighbourhood) is best to optimise efficiencies.

Existing funding flows and financial incentives are often cited as one of the biggest barriers to integrated working and greater collaboration in the NHS. Our Finance and Performance team often gets asked how systems can design financial frameworks to tackle these traditional barriers. The team will therefore share their thoughts on the practical steps that systems can take to facilitate integration through financial mechanisms, such as: system control totals; risk/reward arrangements (such as aligned incentive contracts); and changes to organisational form. A related, burning, question for our capital and estates team is how systems access capital in the future to facilitate transformation? The team will consider the public, private and charitable options in the context of the ‘end of PFI/PF2’ that they previously explored in a blog published at the end of last year PFI/PF2 no more – How will the NHS Transform its Estate?.

Another, very topical debate that our Primary Care Team will address is how clinical leadership and successful involvement of primary care in system-wide governance structures can be facilitated. Many systems consider GP Federations an adequate – if imperfect – vehicle for region-wide engagement but this is likely to change as the newly established PCNs embrace their new roles and responsibilities. Our team will also share their perspective on the tensions between federations and PCNs and the factors that may determine their future relationship and relevance, such as financial incentives for PCNs.

Primary care will also play a lead role in the population health management (PHM) strategies that every ICS has to develop. Our multi-disciplinary population health team will deconstruct the building blocks of a comprehensive, target-oriented PHM approach and outline the ‘no-regrets’ decisions that decision-makers need to consider when negotiating alignment strategies across all system participants. This will also build on the insights provided in the Centre for Health Solutions’ recent publication, The transition to integrated care – Population health management in England, which describes practical suggestions for how population health can be implemented successfully.

A key enabler to PHM is robust analytics capabilities. Our Population Health Analytics team has defined these capabilities and will share lessons from their experience of implementing population health analytics platforms in the ICSs they currently partner with. While the choice of technology and analytics providers is key, systems often struggle with even more basic questions, such as designing legally compliant information governance frameworks for integrated care. One of the main misconceptions our teams work to address is that the Information Governance (IG) frameworks are often seen as a ‘one-off exercise’, rather than a routine set of processes that responds to the constantly evolving legal frameworks.

Once all ICS plans and strategies are in place, disciplined implementation is key, but organisational misalignment or unresolved staff concerns can often impede or derail transformation efforts entirely. While healthcare leaders recognise the pivotal importance of ‘bringing the organisation with them’, they often struggle to dedicate time, effort and funds to the ‘softer’ side of transformation. Our Organisational Development team will share approaches and tools that are cost-effective to implement and which can help organisations align cultures, values and behaviours across fragmented systems to ensure they are ‘transformation-ready’.

Throughout the summer colleagues from our healthcare practice will develop the above topics and share their ideas and suggestions for tackling these high-profile, real-life client challenges. By offering an informed perspective and approach to addressing these issues our aim is to create a dialogue that we hope people will want to engage with. The first blog on ‘system and place-based decision-making for ICS’, will be published by the end of June.


Catherine Skilton - Partner, Public Sector Healthcare Advisory

Catherine is a Partner in Deloitte’s Public Sector Healthcare team. She has worked with the NHS for the past 12 years and leads the firms health work in the South of England. Her specialism is leading projects to optimise operations, covering strategy, mergers & acquisitions, post-merger integration and financial and operational improvement. She has supported a number of systems coming together to form Integrated Care Systems (ICS), including to develop their thinking around organisational form and delivery models.

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