Integrated care systems (ICSs)

We delve into integrate care systems, the impact they have on doctors and what you can do locally to help shape them.

Location: England
Audience: All doctors
Last reviewed: 17 May 2022
NHS Structure Article Illustration

BMA briefing

The UK Government has now passed the Health and Care Act 2022. The Act makes major changes to the NHS in England, including making ICSs formal, statutory bodies with power over NHS commissioning and spending at a local level.

The BMA has produced a member briefing on the Health and Care Act and a dedicated webpage which sets out its the key reforms.

What are ICSs?

ICSs (integrated care systems) are seen by NHS leaders as the future of health and care integration in England. The NHS Long Term Plan and now the Government's Health and Care Bill place ICSs at the heart of the NHS.

As of April 2021, there are 42 ICSs covering every area in England. All 42 are expected to be fully operational as statutory bodies from July 2022. The ongoing development of ICSs presents both challenges and opportunities for doctors.

ICSs bring together NHS, local authority and third sector bodies to take on responsibility for the resources and health of an area or 'system'. Their aim is to deliver better, more integrated care for patients.

Although previously informal and alliance-based, the Government's Health and Care Act enshrines ICSs as statutory bodies.

Specifically, under the Act two bodies – the ICB (Integrated Care Board) and the ICP (Integrated Care Partnership) – will be given statutory status and will collectively make up the ICS. The ICB will be responsible for NHS services and funding, whereas the ICP will cover broader issues such as public health and social care.

Under this structure, the ICB element of the ICS will now take on legal responsibility for NHS resources and commissioning of services within their footprint.

Alongside ICSs, areas in England can also choose to use the ICP (integrated care provider) contract, a more intensive and controversial model of integration. However, only an extremely small number of areas have actively sought to utilise the integrated care provider contract to date.

 

CCGs and ICSs

Under the Health and Care Act, CCGs will be absorbed into ICSs – specifically into their ICBs. Each ICB will take on the commissioning and funding responsibilities that currently sit with their local CCGs. ICBs will also be responsible for broader aims such as strategic planning for their area.

It is expected that most of the CCG staff will transfer to, and be employed by, the relevant ICB. This change is now expected to have taken place by July 2022. NHS England has advised that it is seeking to provide as much stability of employment as possible for those with a current CCG contract.

When changes will come into effect

Although ICSs – via ICBs and ICPs – are expected to be made statutory in July 2022, practical changes have been ongoing for some time already.

The BMA view

The BMA is supportive of efforts to improve collaboration both within the NHS and across the health and care sector, likewise, we recognise the potential value of greater integration.

However, we do not support a single model of integration and have been highly critical of the approach national bodies have taken to the development of ICSs and their predecessors, STPs. The BMA also actively opposed the Health and Care Act during its passage through Parliament and campaigned vociferously for it to be heavily amended.

More specifically, we believe that it is essential for ICSs to embed a strong clinical voice throughout their structures, maintain local decision making, be free from competition and private sector involvement, and be led by the NHS and public accountable bodies.

 

Implications for doctors

Clinical leadership and voice

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 have been lacking so far.

Under the Act, ICBs are required to have at least one representative of primary care on their board - which is expected by NHS England and DHSC to be a GP. However, there is no guarantee of any wider clinical representation on ICBs, which will all determine their wider membership themselves.

For example, LMCs (local medical committees) and LNCs (Local Negotiating Committees) – which represent GPs and secondary doctors respectively, have frequently reported only limited, if any, engagement efforts from their local ICSs. It is critical, therefore, that ICSs reach out to and actively involve their local LMCs and LNCs. Equally, both LMCs and LNCs should directly lobby their local ICSs to amplify their voices within them.

It is also essential that ICBs and ICPs, as the central functions of an ICS, include independent public health doctors in their decision making structures and boards. Again, this has been a considerable challenge in several of the existing ICSs to date.

Oversight of ICSs

The lack of oversight of and guidance for the development of ICSs prior to the Act has meant that there has been no clear sense of what the model should look like or what its responsibilities should be. This has limited the accountability of ICSs and has made it difficult for clinicians and the public to see how their health and care system is changing.

The Health and Care Act and the creation of ICSs as statutory bodies should go some way to resolving this. Though NHS England remain clear that ICSs will be allowed to develop with a high degree of freedom and in a permissive environment, meaning that consistency across the 42 may be limited.

Balancing primary and secondary care

There also remains significant concern among GPs that the ICS model will be dominated by NHS trusts. This concern has been heightened by the decision to have CCGs (clinical commissioning groups) absorbed into ICBs. ICSs must, therefore, make sure there is a strong GP voice within their structures and allow for proper local challenge of their plans from all organisations.

Shared budgets and pooled finances

More developed ICSs are already pooling resources and taking a system-wide approach to financial management, something set to become more and more established in the near future. Organisations within ICSs also adopt and adhere to a shared ‘control total’, which in effect binds them to meeting a collective target for financial performance.

However, as many trusts already struggle to adhere to their own control totals, placing pressure on ICSs to meet a system-wide total may be a risk. 

Drastic cuts to local authority funding have stretched budgets in both public health and social care. This makes it harder for 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.

Multi-disciplinary working

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.

Service transformation

It is possible that organisational mergers may take place as a consequence of ICS plans and local service transformation, with contracts 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.

ICS-level negotiations

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.

Collaboration over competition

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.

The Government’s Health and Care Act seeks to do this, by removing Section 75 of the 2012 Health and Social Care Act, which forces commissioners to competitively tender for contracts.

However, we remain concerned that the proposed replacement - the Provider Selection Regime - could allow for contracts to be handed out without proper scrutiny. Likewise, we are clear that any new system must prioritise the NHS as the preferred provider of NHS contracts and be fully transparent.

Uneven development of ICSs

Many ICSs have faced significant challenges in their development and are still some way from becoming fully operational ICSs.

In contrast, the first ICSs are continuing to progress with their plans, and several are very well established. This disparity presents the risk that a two-tier system could emerge, with levels of integration varying widely.

The NHS Long Term Plan did include a commitment to provide additional assistance for the least advanced systems, though it remains unclear how effective this has been. 

How ICSs work

ICSs work on three key levels.

System

ICSs are made up of two core statutory elements at system level, where major decisions are taken, and overarching strategies agreed:

  1. ICB (Integrated Care Board)

    Focused on core NHS services, the ICB is taking on the roles and responsibilities of CCGs, including commissioning and managing resources.
  2. ICP (Integrated Care Partnership)

    The ICP will have a broader focus, covering public health, social care and wider issues impacting the health and wellbeing of the local population.

Place

Otherwise referred to as Place-based Partnerships, ‘places’ are normally based around towns, cities, or major NHS trusts within a system. Work at ‘place’ level centres on the planning of localised services and secondary and community care. NHS England sees ‘place’ as the key driver of change within ICSs and they are expected to be where the majority of work actually occurs.

Neighbourhood

Neighbourhoods – or localities in some ICSs – are essentially 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.

Graph showing locality of ICSs - ranging from neighbourhood (PCNs), to Place (LCOs, ICPs), to system (ICS,ICP) Graphic showing the broad structure of an ICS

Common themes in existing ICSs

Enhancing the scope of primary and community care

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 and population health improvement

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.

ICS-level workforce planning

Workforce planning is set to increasingly take place at ICS level, with a system-wide approach to recruitment and retention.

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.

Better use of data, tech and innovation

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. 

Service reconfiguration

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.

Principles ICSs must meet

We will judge each new ICS and their plans 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.