By James Banham and Seb Zanker
This latest in our series of blogs on the challenges facing Integrated Care Systems (ICS), focuses on how some commissioners are embracing the proposed model of place-based, shared decision making described in the recent guidance from NHS England and NHS Improvement ‘Designing integrated care systems in England’1; and what steps they are taking to transition from transactional to more strategic activities.
How are ICS’s operationalising joined-up, placed-based strategy setting and decision making?
While integration holds the promise of better, more patient-focussed care, the organisational transformations that enable this are often long and complex. In some instances systems struggle to make place-based decisions due to diverging views and varying levels of trust amongst the system’s constituent actors, which is not surprising given the pressures applied to relationships by existing structures such as the commissioner-provider split.
In this context the question of how to make progress is an interesting one. Ordinarily many people would argue that form should follow function and, therefore, that the governance and decision making will spring out of delivery. Some places are doing this successfully by delivering transformation through reconfiguring acute services or building out of hospital models, and then building structures as a result.
However, other places find this difficult, because of the barriers thrown up by existing structures. In such cases, we have found that places can make progress by clarifying their governance and decision making structures from the beginning of the transformation journey. In our experience this early clarity can give systems ‘grip’ and confidence. We have worked with systems to build these enabling structures and learnt that defining a system’s approach to setting up the following forums can accelerate the quality of conversations between organisations in a complex, uncertain, multi-stakeholder environment (see Figure 1 and the descriptions below).
Figure 1: Example of an ICS operating model
- System Partnership Boards (SPBs) bring together commissioners and providers to agree the outcomes the system wants to achieve; design an outcomes framework to hold the system to account; and set a strategy for the health and social care economy to make progress towards these outcomes.
- The Strategic Commissioner will commission the delivery of the system strategy and outcomes through the Integrated Care Providers and allocate resources accordingly. In many places this is currently being formed by merging Clinical Commissioning Groups (CCGs). Some places have been able to bring in local authorities and create Joint Commissioning Boards, through pooling staff in Commissioning Hubs, which take forward activities on behalf of the entire system.
- Integrated Care Providers (ICPs) bring together primary, community, mental health, acute and social care services around a local place/population and as such are a key delivery vehicle for integrated care.
- Primary Care Networks (PCNs) will design and deliver local services for their populations and may include a range of local stakeholders, built around general practice.
What are the key issues that systems are grappling with in establishing their structures?
The above structures are a starting point but the difficulties defining some of this detail should not be underestimated. We have found the systems that make progress on this agenda are those which include time for continual debate and discussion of the key issues, iterating until progress is made.
Some of the sticking points that can prevent progress include:
- The makeup of ICPs: critically ICPs can take many forms from loose alliances to contractual arrangements or the full mergers seen in Greater Manchester. The new integrated care provider contract will be a key enabler for establishing contractual arrangements. We advise starting with an alliance, tasking the ICP with a key work programme (for example, delivering a new MSK pathway), and building relationships and further structures from there. Otherwise there is a significant risk that ICPs continue to exist as ‘talking shops’ with little influence or status.
- The role of general practice: general practice must be an equal partner in the Partnership Board and the ICPs, but establishing this is tricky, and also requires a fundamental shift in the role of GPs in developing services. Some systems are considering creating a representative structure for PCNs and then creating a co-chair arrangement of ICPs shared between a PCN representative and a provider representative. Others are just getting on with delivery with GPs working side by side with transformation teams in local hospitals.
- Decision making: none of these structures have statutory force, so all decision making has to go through the constituent organisations, making approval processes unwieldy. It will take time before this issue can be resolved, in the meantime, it is critical that each organisation commits to having the right person in the room at every level of the ICS. If ICPs are to be more than ‘talking shops’, they require senior provider input that supports new ways of working.
- Membership: deciding the role of private providers and the voluntary sector is often a challenge, as is determining PCN representation, and creating a genuinely representative structure for primary care providers. Too many representatives around the table dilutes efficiency but promotes engagement. Detailed discussions between partners are needed to determine an appropriate balance of members for each ICS.
- Relationships: many of the difficulties revolve around the relationships between the different layers of the system. For example, what can be devolved from ICPs to PCNs; how much autonomy will there be for individual neighbourhoods, when might it be in the overall ICP’s interest to have a certain amount of standardisation? This has to be worked through on a case by case basis depending on the set of services being considered, and building an operating model from the bottom up.
What do these changes mean for commissioners?
The above approach means significant change for Clinical Commissioning Groups (CCGs), both in structure, but also in roles and functions. We have done a lot of thinking on these issues and have helped commissioners define more clearly what responsibilities and functions look like for a single, strategic commissioner. Figure 2 illustrates a framework of capabilities that commissioners will need to develop to help drive a successful integration.
Figure 2: What Strategic Commissioners will look like in the future
It’s important not to lose sight of why the above changes are needed. In this regard a clear, compelling narrative explaining ‘why do it’ is really important, and must be repeatedly communicated. In particular, front line staff can often be neglected through these processes and conversations. We have found that if you involve staff and clinicians in co-producing the operating model and how this will work in practice, you have a better chance of success.
In reality, what we have today are relatively immature structures, with change likely to be gradual, and will require transition arrangements. Consequently, all stakeholders need to do everything they can to increase the levels of maturity across the ICS, inch by inch, finding pragmatic ways of building consensus and making progress.
Creating the above structures alone will not resolve all the fundamental issues facing an ICS but the debates initiated by creating them can help systems to progress their thinking and build the necessary relationships.
1 Designing integrated care systems in England. NHSE, 19 June 2019. See also: https://www.england.nhs.uk/publication/designing-integrated-care-systems-icss-in-england/