Integrated care system

In England, an integrated care system (ICS) is a statutory partnership of organisations who plan, buy, and provide health and care services in their geographical area. The organisations involved include the NHS, local authorities, voluntary and charity groups, and independent care providers. The NHS Long Term Plan of January 2019 called for the whole of England to be covered by ICSs by April 2021. On 1 July 2022, ICSs replaced clinical commissioning groups in England.

Statutory bodies

The Health and Care Act 2022 put these systems on a statutory basis, each with an approved constitution. On 1 July 2022, a total of 42 ICSs became statutory. There are more than 70 performance metrics by which they are judged, grouped into six "oversight themes": quality, access and outcomes, preventing ill health and reducing inequalities, leadership, people, and finances. The poorest performers will be put in a "recovery support programme", which will replace the label of special measures. Each system is to set their own constitution, determine staff pay and can raise "additional income" but the chair must be approved by the Secretary of State for Health and Social Care.

The areas covered by each ICS vary considerably by population and demographics. Population size ranges from 500,000 to more than 3 million people. Some have more than 10 upper-tier local authorities and some only one. Nearly 50% of the neighbourhoods in Birmingham and Solihull are in the most deprived fifth of the neighbourhoods nationally, compared to 1% in Surrey Heartlands.

Governance

NHS England produced a model constitution in July 2021, which systems are expected to use when developing their own arrangements. Each ICS must have an integrated care board with at least five executive directors and three non-executives.

Integrated care partnership

The boards must work with local authorities to create an integrated care partnership (ICP) committee for each system, to include local organisations such as the voluntary sector and social enterprises. The ICP works on prevention, wider social and economic factors affecting health, and reducing health inequalities.

Pharmacy

Each ICS is to have a community pharmacy clinical lead, funded by the Pharmacy Integration Programme for the first two years.

History

The first accountable care systems (2017)

Eight sustainability and transformation plan areas in England were named in June 2017 by Simon Stevens, chief executive of NHS England, as a first wave in the development of what were then called accountable care systems. He said they "will bring together providers and commissioners to help break down barriers between primary, secondary and social care". They would be given up to £450 million between them in transformation funding over the next 4 years. The eight were:

• Frimley Health and Care System – a consortium of 30 public and private care providers with five clinical commissioning groups, five GP federations, 10 local, district and county authorities, two ambulance trusts and five mental health and community providers including Virgin Care;
• South Yorkshire and Bassetlaw – seven NHS hospital trusts covering 15 hospital sites, which employ 45,000 staff and service 2.3 million residents;
• Nottinghamshire – with an initial focus on Greater Nottingham and the southern part of the sustainability and transformation partnership; includes seven public bodies and Circle Health;
• Blackpool and Fylde Coast, with the potential to spread to other parts of the Lancashire and South Cumbria STP at a later stage;
• Dorset;
• Luton, with Milton Keynes and Bedfordshire;
• West Berkshire;
• Buckinghamshire.

Greater Manchester was not included because it already had more advanced arrangements under its 2015 "devolution" deal. Surrey Heartlands began a similar arrangement in 2018.

In each area a provider or, more usually, an alliance of providers will collaborate to meet the needs of a defined population with a budget determined by capitation. There will be a contract that specifies the outcomes and other objectives they are required to achieve within the given budget over a period of time. This may extend well beyond health and social care services to encompass public health and other services. In Manchester, the objectives are specified over ten years. Keeping people out of hospital by moving services into the community is a common feature. NHS trusts, Clinical Commissioning Groups and local authorities in the new ACSs will "take on clear collective responsibility for resources and population health".

The process was denounced by John Sinnott, Chief Executive of Leicestershire County Council in September 2017 as lacking any element of public accountability. He said that existing models in other countries were interesting but not relevant to democratic accountabilities in the UK since they had different governance structures and forms of service provision.

It is proposed that systems employing general practitioners would have to meet the costs of their indemnity insurance.

In September 2017 NHS England produced a handbook designed to support the creation of new payment models which are intended to remove the direct relationship between NHS activity and payment, improve the alignment of payment for all providers within the care model and better incentivise prevention and wellbeing.

Integrated care systems (2018-)

In February 2018 it was announced that these organisations were in future to be called integrated care systems, and that all 44 sustainability and transformation plans would be expected to progress in this direction. The ten pioneer systems were described as nascent and fragile by the Health Select Committee in May 2018. They were described by Chris Ham as "coalitions of the willing" in 2018. He said that real progress had only happened in places where there was a history of collaborative working. He also commented that there was little guidance and so more latitude than is usually the case with national NHS initiatives.

In January 2019 it was announced in the NHS Long Term Plan that by April 2021 integrated care systems were to cover the whole of England with a single clinical commissioning group for each area. Each one will be run by a partnership board with members from commissioners, trusts, and primary care. But it has been suggested that "All ICSs are structured differently as there is no fixed model for how they should be developed; and the leadership is defined in terms of roles and agents, with little to guide leadership practices and behaviours in a complex, collaborative governance arrangement"

Three more areas were designated in June 2019, and four more in May 2020 (Hertfordshire and West Essex, Humber, Coast and Vale, South West London, and Sussex), bringing the total to 18.

Nineteen NHS minority ethnic leaders demanded in March 2021 that the executive officers (not just the non-executives) in the 42 emerging ICSs should be representative of the ethnic diversity in their communities. They wanted to see ethnic diversity and inclusion a part of every NHS board's core business and that every system should develop a 10-year strategy, with annual milestones, for reducing inequalities. In July 2021 chairs had been appointed for 25 of the 42 NHS integrated care boards. 11 are women, and five have a minority ethnic background. The chairs must not be councillors or MPs, or to work for any of their ICS's constituent organisations.

Integrated care providers

A consultation on the draft contracts for what were then called integrated care providers (ICPs) was launched by NHS England in August 2018 after the failure of two legal challenges to an earlier draft contract. The consultation said that this was not a new type of legal entity, but merely the "provider organisation which is awarded a contract by commissioners for the services which are within scope." Dudley clinical commissioning group is at the forefront of this exercise and will be able to implement the draft voluntary contract, subject to the outcome of this consultation exercise. It is proposed that general practitioners will be able to sign fully or partially integrated contracts, and that fully integrated practices would give up their existing contracts to become salaried.

Evaluation

A report from the Nuffield Trust in December 2021 found that there was very little evidence that integration policies across the UK – including pooling budgets and creating new integrated boards and committees – had dramatically improved patient experience, quality of services or supported the delivery of more care outside of hospitals. They warned that without concurrent investment in social care and broader public services, it was “very likely” further reforms would not yield the desired results.

Integrated Care Boards

On 1 July 2022 NHS England established 42 integrated care boards, covering the whole of England.

Name	Local authority areas covered
NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board	Bath and North East Somerset, Swindon, Wiltshire, and part of the Vale of White Horse
NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board	Bedford, Central Bedfordshire, Luton, Milton Keynes, and part of Buckinghamshire
NHS Birmingham and Solihull Integrated Care Board	Birmingham and Solihull
NHS Black Country Integrated Care Board	Dudley, Sandwell, Walsall, and Wolverhampton
NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board	Bristol, North Somerset, and South Gloucestershire
NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board	Cherwell, Oxford, Reading, South Oxfordshire, West Berkshire, West Oxfordshire, Wokingham, part of Buckinghamshire, and part of the Vale of White Horse
NHS Cambridgeshire and Peterborough Integrated Care Board	Cambridge, East Cambridgeshire, Fenland, Huntingdonshire, Peterborough, South Cambridgeshire, and part of North Hertfordshire
NHS Cheshire and Merseyside Integrated Care Board	Cheshire East, Cheshire West and Chester, Halton, Knowsley, Liverpool, Sefton, St Helens, Warrington, and Wirral
NHS Cornwall and The Isles of Scilly Integrated Care Board	Cornwall and the Isles of Scilly
NHS Coventry and Warwickshire Integrated Care Board	Coventry, North Warwickshire, Nuneaton and Bedworth, Rugby, Stratford-on-Avon, and Warwick
NHS Derby and Derbyshire Integrated Care Board	Amber Valley, Bolsover, Chesterfield, Derby, Derbyshire Dales, Erewash, High Peak, North East Derbyshire, and South Derbyshire
NHS Devon Integrated Care Board	East Devon, Exeter, Mid Devon, North Devon, Plymouth, South Hams, Teignbridge, Torbay, Torridge, and West Devon
NHS Dorset Integrated Care Board	Bournemouth, Christchurch and Poole, and Dorset
NHS Frimley Integrated Care Board	Bracknell Forest, Rushmoor, Slough, Windsor and Maidenhead, part of Hart, part of Surrey Heath, part of Guildford, part of Runnymede, and part of Waverley
NHS Gloucestershire Integrated Care Board	Cheltenham, Cotswold, Forest of Dean, Gloucester, Stroud, and Tewkesbury
NHS Greater Manchester Integrated Care Board	Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford, and Wigan
NHS Hampshire and Isle of Wight Integrated Care Board	Basingstoke and Deane, East Hampshire, Eastleigh, Fareham, Gosport, Havant, the Isle of Wight, New Forest, Portsmouth, Southampton, Test Valley, Winchester, and part of Hart
NHS Herefordshire and Worcestershire Integrated Care Board	Bromsgrove, Herefordshire, Malvern Hills, Redditch, Worcester, Wychavon, and Wyre Forest
NHS Hertfordshire and West Essex Integrated Care Board	Broxbourne, Dacorum, East Hertfordshire, Epping Forest, Harlow, Hertsmere, St Albans, Stevenage, Three Rivers, Uttlesford, Watford, Welwyn Hatfield, and part of North Hertfordshire
NHS Humber and North Yorkshire Integrated Care Board	East Riding of Yorkshire, Hambleton, Harrogate, Kingston upon Hull, North East Lincolnshire, North Lincolnshire, Richmondshire, Ryedale, Scarborough, Selby, and York
NHS Kent and Medway Integrated Care Board	Ashford, Canterbury, Dartford, Dover, Folkestone and Hythe, Gravesham, Maidstone, Medway, Sevenoaks, Swale, Thanet, Tonbridge and Malling, and Tunbridge Wells
NHS Lancashire and South Cumbria Integrated Care Board	Barrow-in-Furness, Blackburn with Darwen, Blackpool, Burnley, Chorley, Fylde, Hyndburn, Lancaster, Pendle, Preston, Ribble Valley, Rossendale, South Lakeland, South Ribble, West Lancashire, Wyre, part of Copeland, and part of Craven
NHS Leicester, Leicestershire and Rutland Integrated Care Board	Blaby, Charnwood, Harborough, Hinckley and Bosworth, Leicester, Melton, North West Leicestershire, Oadby and Wigston, and Rutland
NHS Lincolnshire Integrated Care Board	Boston, East Lindsey, Lincoln, North Kesteven, South Holland, South Kesteven, and West Lindsey
NHS Mid and South Essex Integrated Care Board	Basildon, Braintree, Brentwood, Castle Point, Chelmsford, Maldon, Rochford, Southend-on-Sea, and Thurrock
NHS Norfolk and Waveney Integrated Care Board	Breckland, Broadland, Great Yarmouth, King's Lynn and West Norfolk, North Norfolk, Norwich, South Norfolk, and part of East Suffolk
NHS North Central London Integrated Care Board	Barnet, Camden, Enfield, Haringey, and Islington
NHS North East and North Cumbria Integrated Care Board	Allerdale, Carlisle, Durham, Darlington, Eden, Gateshead, Hartlepool, Middlesbrough, Newcastle-upon-Tyne, North Tyneside, Northumberland, Redcar and Cleveland, South Tyneside, Stockton-on-Tees, Sunderland, and part of Copeland
NHS North East London Integrated Care Board	Barking and Dagenham, City of London, Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest
NHS North West London Integrated Care Board	Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, and the City of Westminster
NHS Northamptonshire Integrated Care Board	North Northamptonshire and West Northamptonshire
NHS Nottingham and Nottinghamshire Integrated Care Board	Ashfield, Bassetlaw, Broxtowe, Gedling, Mansfield, Newark and Sherwood, Nottingham, and Rushcliffe
NHS Shropshire, Telford and Wrekin Integrated Care Board	Shropshire and Telford and Wrekin
NHS Somerset Integrated Care Board	Mendip, Sedgemoor, Somerset West and Taunton, and South Somerset
NHS South East London Integrated Care Board	Bexley, Bromley, Greenwich, Lambeth, Lewisham, and Southwark
NHS South West London Integrated Care Board	Croydon, Kingston upon Thames, Merton, Richmond upon Thames, Sutton, and Wandsworth
NHS South Yorkshire Integrated Care Board	Barnsley, Doncaster, Rotherham, and Sheffield
NHS Staffordshire and Stoke-on-Trent Integrated Care Board	Cannock Chase, East Staffordshire, Lichfield, Newcastle-Under-Lyme, South Staffordshire, Stafford, Staffordshire Moorlands, Stoke-on-Trent, and Tamworth, Staffordshire
NHS Suffolk and North East Essex Integrated Care Board	Babergh, Colchester, Ipswich, Mid Suffolk, Tendring, West Suffolk, and part of East Suffolk
NHS Surrey Heartlands Integrated Care Board	Elmbridge, Epsom and Ewell, Mole Valley, Reigate and Banstead, Spelthorne, Tandridge, Woking, part of Guildford, part of Runnymede, part of Chichester, part of Surrey Heath, and part of Waverley
NHS Sussex Integrated Care Board	Adur, Arun, Brighton and Hove, Crawley, Eastbourne, Hastings, Horsham, Lewes, Mid Sussex, Rother, Wealden, Worthing, and part of Chichester
NHS West Yorkshire Integrated Care Board	Bradford, Calderdale, Kirklees, Leeds, Wakefield, and part of Craven

External links

• Official website