The BMA has responded to new legislative proposals put forward by NHS England which would see ICSs made statutory bodies and could dramatically alter the role of CCGs.
ICSs (integrated care systems) are now seen by NHS leaders as the future of health and care integration in England. The NHS Long Term Plan established a target for every area in the country to be covered by one by 2021.
There are currently 14 ICSs across England, with more set to emerge. Their development presents both challenges and opportunities for doctors.
What are ICSs?
ICSs are a way of planning and organising the delivery of health and care services. They bring together NHS, local authority, and third sector bodies to take on collective responsibility for the resources and health of an area. This aims to deliver better, more integrated care for patients.
ICSs do not require contractual or structural change. Instead, they are an alliance agreement between member organisations which overlays regular commissioning processes and contracts.
Implications for doctors
NHS England and individual ICSs have stressed that clinical input will be central to their progress and to their leadership. However, clinical engagement remains an area where ICSs, like STPs, have been lacking so far.
A number of LMCs (local medical committees) have, for example, reported only limited, if any, engagement efforts from their local ICSs.
We therefore welcome the commitment in the
NHS Long Term Plan that every ICS should actively engage with a clinical director from
each PCN within its system.
Equally, engagement with secondary care clinicians has been poor, with very few frontline hospital doctors involved in the development of their ICS.
It is essential that ICSs effectively engage and involve local authorities in their work, particularly in respect of efforts to improve public health and social care. Again, this has been a considerable challenge in several of the existing ICSs to date.
The lack of oversight or guidance for the development of ICSs means that there is no
clear sense of what the model should look like or what its responsibilities should be.
This limits the accountability of ICSs and makes it difficult for clinicians and the public to determine how their health and care system is changing.
There remains significant concern among GPs that the model is often dominated by NHS trusts. Therefore, ICSs must also allow for proper local challenge of their plans from all organisations.
Many trusts may struggle to adhere to their own individual control totals, placing enormous pressure on ICSs to meet a system-wide total.
Drastic cuts to local authority funding have severely stretched budgets in both public health and social care. This reduces the capacity of those services to relieve pressure on the NHS and risks undermining integration.
NHS England must take this into account when system control totals are set and when priorities for integration are agreed.
The co-ordination of care across wider areas is expected to increasingly involve doctors working across multiple sites and as part of MDTs.
This could give doctors the chance to work in different environments and more closely with colleagues across primary and secondary care, something which has been identified as improving patient care by doctors.
This could also mean that doctors’ patterns of work may change. Passporting and staff portability systems are likely to be introduced in all ICSs, to allow doctors and staff to work in different sites.
Where mergers do take place, contracts may be transferred to other trusts via TUPE (transfer of undertakings (protection of employment)).
All doctors should at the bare minimum be employed on nationally agreed terms and conditions, with their training time fully protected. Any changes must only happen in
consultation and with the agreement of the BMA.
It may be the case that as individual hospitals and staff increasingly operate as part of the wider system, place-based negotiations will need to take place on a wider scale, potentially at ‘place’ or even ‘system’ level.
Equally, the pay and conditions of doctors working in different or atypical environments may need to be altered to reflect their new roles and responsibilities. This could, for example, apply to GPs working in emergency departments.
The BMA has been consistently critical
of competition within the NHS, which we believe is bad for patients, staff and integration.
The ICS model’s focus on collaboration
over competition could, then, allow integration to flourish. But to ensure that this can happen, costly and burdensome rules on competition should be removed.
Many STPs have faced significant challenges in their development and are still some way from becoming an ICS.
The existing 14 ICSs are continuing to progress with their plans and should be well established by 2021. This disparity presents the risk that a two-tier system could emerge, with levels of integration varying widely.
The NHS Long Term Plan does include a commitment to provide additional assistance for the least advanced systems.
What you can do
BMA members across all branches of practices have a vital role to play in deciding the future direction of services in your area. We encourage you to engage with local decision-making structures in your area.
- Engage with your local CCG - an important means of influencing reform of the system in your area.
- Engage through existing structures and influence
your trust’s leadership.
- Contact your LNC and ask that they raise both ICS/STP engagement, and staff portability with your trust.
- Get involved in local bodies such as LMCs, LNCs, and BMA regional councils, so that the profession’s collective voice is as strong as possible at a local level.
We've produced a guide for you to get your voice heard locally and get the most from engagement.
How ICSs work
ICSs work on three key levels.
Work is focused on partners working together to set strategy, finance, workforce planning, and agree overall levels of integration.
Normally based around towns within a system. Work at ‘place’ level centres on the planning of localised services and secondary and community care.
This level is based around PCNs (primary care networks), groups of GP practices covering populations of 30,000 to 50,000 people. Multi-disciplinary teams are central to PCNs, with clinicians and health professionals from a wide range of services working together.
ICS leaders also take on responsibility for the financial and operational performance of the organisations within their system.
Common themes in existing ICSs
This will revolve around the development of PCNs and the use of integrated MDTs (multi-disciplinary teams) across primary and community care.
NHS England see PCNs as central to the provision of integrated, at-scale primary care. They include services beyond core general practice
and work closely with acute, community and mental health trusts, as well as with
pharmacy, voluntary and local authority services.
Prevention is a national priority and it is a major element of the NHS Long Term Plan, which also includes increased promotion of self-care and social prescribing.
The wider determinants of health are also an emerging focus for a number of ICSs. Buckinghamshire ICS has, for example, looked at the impact housing, employment and access to green space can have on population health.
Some ICSs are prioritising the use of new clinical roles to support their work, including employing physician associates and advanced nurse practitioners. The South Yorkshire and Bassetlaw ICS, for example, views these new roles as a means of tackling workforce challenges and freeing-up clinicians’ time in both primary and secondary care.
ICSs are also considering how doctors can work differently and, in some cases, across the system as a whole. This includes the use of ‘passporting’ and portability systems, to allow staff to move and work between different sites and organisations within the ICS.
This is centred around improving IT integration and the sharing of patient records. It is perceived that the challenges that have plagued these initiatives previously may, in part, be overcome through system-working.
Data sharing is a core focus, with several areas, including Dorset ICS, working towards establishing shared patient records within their systems.
Dorset ICS is also operating what it calls ‘360 degrees transparency’, with all NHS member organisations expected to share and be transparent with their workforce, finance, and performance data.
Dorset and South Yorkshire and Bassetlaw ICSs, have, for example, undertaken reviews of their existing services, with a view to potential future reconfiguration of secondary care.
The South Yorkshire and Bassetlaw review recommended that clinical, or ‘hosted’ networks be established, with different hospitals taking responsibility for different specialist services,
concentrating speciality care at specific sites.
The NHS Long Term Plan includes a call
for legislative change to ease the merger of NHS bodies, including trusts, which may mean that trust mergers become more likely in the future.
Any service reconfiguration must be led
by clinicians, be based on clinical evidence, and must not be driven by financial pressures.
The NHS Long Term Plan includes an aspiration to have a single set of commissioning arrangements within individual ICSs. According to the plan, this will typically involve a single CCG covering a single ICS.
However, ICSs will continue to vary in size and may not be in line with with CCG boundaries, which may make this process highly complex in some areas.
Commissioning within ICSs is also expected to change, with the possibility that providers will increasingly take responsibility for some of the day-to-day functions currently carried out
by CCGs, such as the design of care pathways. This shift would then see CCGs focus on more strategic issues, such as patient outcomes, population health, and financial governance.
This includes making arrangements for risk sharing and decisions on how services will be paid for. They will also be required to approve a system control total, defined by NHS England as the aggregate required income and expenditure position for trusts and CCGs within the system. Access to sustainability funding will be linked to performance against the totals.
Principles ICSs must meet
We will judge each new STP and ICS plan against these criteria and expect NHS England’s priorities for integration to meet them:
- ensure the pay and conditions of all NHS staff are fully protected
- protect the partnership model of general practice and GPs’ independent contractor status
- only be pursued with demonstrable engagement with frontline clinicians and the public, and must allow local stakeholders to challenge plans
- be given proper funding and time to develop, with patient care and the integration of services prioritised ahead of financial imperatives and savings
- be operated by NHS and publicly accountable bodies, free from competition and privatisation.